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UNDERGROUND STORAGE TANK <br /> TANK AND LINE INTEGRITY TESTING, AND ENHANCED LEAK <br /> DETECTION TEST NOTIFICATION FORM <br /> OFFICE OF TANK TESTER LICENSING <br /> OTTLC@-C@ <br /> Test notifications for testing tank and line integrity testing, and enhanced leak detection (ELD) <br /> testing are required to be submitted to the Office of Tank Tester Licensing (OTTL) in accordance <br /> with the California Code of Regulations, tile 23, chapter 17, section 2772. If changes to test <br /> notifications occur after submittal to OTTL, please notify OTTL of those changes immediately. <br /> Using this form, provide OTTL with the following information when submitting test notifications: <br /> SUBMITTAL DATE: 5/19/2021 <br /> FACILITY INFORMATION <br /> CERS ID 10181085 Test Date and Time 5/21/2021 11 :30am <br /> Facility Name Country Mart Gas & Food <br /> Facility Address 34243 S Chrisman Rd City Tracy ZIP Code 95376 <br /> TANK TESTER INFORMATION <br /> Company Performing the Test Afforda-Test Phone 209 744-0112 <br /> Mailing Address 416 2nd St Galt, CA <br /> Licensee Name Zane Nimmo <br /> OTTL License # 04-1676 Expiration Date 3/31/2022 <br /> TEST METHOD INFORMATION <br /> Test Method Components Tested <br /> Petro Tite II Line Test <br /> Post Construction ELD: Is the form for post construction contractor statement attached? <br /> YES ❑ NO If no is selected, provide general contractor statement prior to testing. <br /> Failure to comply and provide all of the above information may result in disciplinary action against <br /> licensed tank tester. Please note that this notification does not waive the requirement for the <br /> 48-hour notice to the local agency in accordance with the provisions of California Code of <br /> Regulations, title 23, chapter 16, sections 2643(g) and 2644.1(a)(4). <br /> June 2020 <br />