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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 /> OTTL(a-)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: 04/27/2023 <br /> FACILITY INFORMATION <br /> CERS ID 10403278 Test Date and Time 05/23/2023 12:00 PM <br /> Facility Name Verizon Lodi CA FO Term (Intl) <br /> Facility Address 2500 W. Turner Rd. City Lodi ZIP Code 95242 <br /> TANK TESTER INFORMATION <br /> Company Performing the Test SunWest Eng. Constructors, Inc. Phone (909) 594-9850 <br /> Mailing Address4780 Cheyenne Way, Chino, CA 91710 <br /> Licensee Name Albert QueiroS <br /> OTTL License #91 -1448 Expiration Date 06/30/2023 <br /> TEST METHOD INFORMATION <br /> Test Method Components Tested <br /> Triangle TEI LT-3 underground product piping <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 />