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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@_waterboards.ca.gov <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: 1/4/2021 <br />FACILITY INFORMATION <br />CERS ID 10180877 <br />Test Date and Time 1/4/2021 1:30p <br />Facility Name western Food & Fuel <br />Facility Address 3032 E Waterloo <br />City Stkn <br />ZIP Code 95205 <br />TANK TESTER INFORMATION <br />Company Performing the Test Afforda-Test <br />Phone 209 744-0112 <br />Mailing Address 416 2nd St Galt, Ca. <br />Licensee Name Zane Nimmo & Felix Ramirez <br />OTTL License # 04-1676 Zane 08-1740 Felix <br />Expiration Date 3/31/2021 <br />TEST METHOD INFORMATION <br />Test Method <br />Components Tested <br />Triangle Env Tri Tester <br />Tank & Annular <br />Test is for site only - Potential Problem, didn't want to wait another 48 hours <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 />