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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-Ca�_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: 05/04/2023 <br />FACILITY INFORMATION <br />CERS ID N/A <br />Test Date and Time Tuesday, 05/09/23 @ 8am <br />Facility Name Edgewood <br />Facility Address 4600 S. Carrol Hollow Road <br />City Tracy <br />ZIP Code 95377 <br />TANK TESTER INFORMATION <br />Company Performing the Test CGRS <br />Phone (916) 991-1100 <br />Mailing Address 5444 Dry Creek Rd. <br />Licensee Name Sergio Nunez <br />OTTL License # 06-1727 <br />Expiration Date 07/31/2024 <br />TEST METHOD INFORMATION <br />Test Method <br />Components Tested <br />iota® VaporTite V005 / iotaVision TM L005 <br />87/91 /Diesel <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 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 />