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V 'se°uu.s STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �ymb d UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B `<. - , 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE IL1� ONE ITEM ❑ 2 INTERIM PERMIT ® 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED /C7 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A. Teichert & Son Inc. 03 LL `St 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# C-11 North B. MANUFACTURED BY: Unknown C. DATE INSTALLED(MOIDAYNEAR) 19 7 2 D. TANK CAPACITY IN GALLONS: 20 , 000 ILTANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ® 1 MCTORVEHICUE FUEL ❑ 4 OIL B. C, 1A REGULAR UNLEADED ® 3 DIESEL ❑ B AVIATIONGAS ❑ 2 ❑ 80 EMPTY ® i PRODUCT ❑ 1b PREMIUM UNLEADm ❑ 4 GASAHOL ❑ ] METHANOL ❑ Ic MOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 DUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEM D.BELONG D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ® I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WA=RP (PdMWY Too) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE E]95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION EM SPILLCONTAINMENT STALLED(YEAR) OVERFILL PREVENTION QUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,BtC. DROPTUBE YES NO_ STRIMER PLATE YES_ NO DI SPENSERCONTAINME YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A(t)2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ®1 MECNN M UNE Ue ❑2 LME MIO E% ❑3 CONM JWS IxrEnsTrrLu ❑4 ELr:cmamc UNE [::]5 AUTaunC MW O 99 GTHER DETECTION TEsnxG NOMraRND LEAK OETECT011 sNUmowx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ® 2 RECONCILIATIONORY ❑ 3 MONITORING ZE ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORING TER ❑6 ANNUALTESTING ❑ 7 CONTINUOUS INTERSTITIAL ❑NITORING 8 SIR ❑ 9 WEETANK LY MANUAL ❑10 M SMTMGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DA LAST ( R) 2.EMATED OUANTITY OF 3.WAS TANK FILLED WITH YES E] NO -V-7 /` SUSTIBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FOR14 HAS BE N COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED A SIGNATURE) George Takemori 12-1-98 LOCAL AGENCY USE ONLe THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK k STATE I.D.# m7JE-z:�c1ti15 y PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE 1-4-44 0 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICAIJON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FARM':MUST BE COMPLETED FOR INSTALLATIONS. THIS/ SHOULD BE ACCOMPANIED BY A PLOT F FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH AGROUND STORAGE TANK REGULATIONS FORMS �/� FORMS (8-95) �� 7 ,!� - y