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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 /> OTTI-C@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: 10/13/2026 <br /> FACILITY INFORMATION <br /> CERS ID NSA Test Date and Time Wednesday, 10/21/26 @ 8am <br /> Facility Name COStCO 1091 <br /> Facility Address 2680 Reynolds Ranch Pkwy City Lodi <br /> ZIP Code 95240 <br /> TANK TESTER INFORMATION <br /> Company Performing the Test CGRS Phone 916-991-1100 <br /> Mailing Address 5444 Dry Creek Rd - Sacramento, CA 95838 <br /> Licensee Name Adam Montejano <br /> OTTL License # 1775 Expiration Date 08/31/2027 <br /> TEST METHOD INFORMATION <br /> Test Method Components Tested <br /> iota@ VaporTite V005 / iotaVision TM L005 87/91/Diesel/Gas Additive <br /> Post Construction ELD: Is the form for post construction contractor statement attached? <br /> -'] YES -1 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 48- <br /> hour notice to the local agency in accordance with the provisions of California Code of Regulations, <br /> title 23, chapter 16, sections 2643(g) and 2644.1(a)(4). <br /> June 2020 <br />