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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(o)-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:11/2/23 <br /> FACILITY INFORMATION <br /> CERS ID Test Date and Time: 11/6/23 @ 9 am <br /> Facility Name: Mountain House AMPM <br /> Facility Address: 18095 W Grant Line RD City: Mountain House ZIP Code: 95391 <br /> TANK TESTER INFORMATION <br /> Company Performing the Test: LEAK DETECTION TECHNOLOGIES Phone :8552555325 X 746 <br /> Mailing Address:2765 e WIEDING RD, TUCSON, AZ 85706 <br /> Licensee Name: RICARDO GONZALEZ <br /> OTTL License #04-1695 Expiration Date: 05/31/26 <br /> TEST METHOD INFORMATION <br /> Test Method: Components Tested <br /> Enhanced Leak Detection Under Ground Storage Tank <br /> System <br /> Post Construction ELD: Is the form for post construction contractor statement attached? <br /> �YESI 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 />