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STATE OF CALIFORNIA '� STATE WATER RESOURCES CONTROL BOARD i d� o 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B � . I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEMEl 2 INTERIM PERMIT ® 4 AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE S TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: A. TeiChert & Son, Inc. 3 , . I. TANK DESCRIPTION COMPLETE ALL ITEMS-�SPPECIFY IF UNKNOWN A OWNER'S TANK 1.0.# C-11 South I*- B. MANUFACTURED BY: Unknown C. DATE INSTALLED(MO/DAWYEAR) 19 7 2 D. TANK CAPACITY IN GALLONS: 20, 000 II.TANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 18 REGUTAP UNLEADED ® 3 DIESEL ❑ S AVIATION GAS 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT ❑ 1b PREMUM UNLEADED ❑ 4 GASOHOL ❑ 7 METHANOL ❑ ❑ 1e MIDGRADE UNIFADEDn�`–� S JET FUEL ❑ 8 MBS ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN E:] 2 WASTE ❑ 2 LEADED u 99 OTHER(DESCRIBE N TEND.BELON? D. IF(Al)IS NOT MARKED. ENTER NAME OFSUBSTANCE STORED C.A.S-# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL O 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 ® 1 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 COMPATBLE W/FRP (P,I-q Tank) ❑ 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 PROTECTION ❑ 5 CATHODIC PROTECTION ® 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL.BLF SPILL CONTAINME STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES NO_ STRIKER PLATE VES_ NO DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(U> PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 9 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 6 CONCRETE A U 7 STEEL W/COATING A U a 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 KQWflC UNE tEAK O 2 ME TIOMNE95 O 3 CONIINUmS IMER3TIT91 �4 RECfRONN UNE O 5 AUfOMATC mw � 99 OTHER 9EIE" TESnW AgwO LEAK 6EIECTOR 9aDDOWp V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ® 2 MANUAL RECONCILIATION RY ❑ 3 MONITORING ❑ 4 AUTOMATIGAUGING MONITORING TANK ❑ 5 MOONTORINGROUND TER ❑ 6 ANNUALTESTING ❑ 7 MONITORING INTERSTITIAL O 6 SIR ❑ 9 WEETANKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED D TE LAST UDSR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUB STA NCE REMAINING GALLONS INERT MATERIAL ❑ THIS FOdM HAS B EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME I DATE (PRIMED 631ONATURE) George Takemori 12-1-98 LOCAL AGENCY USE ONL THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#1" TANK# STATE LD:# m PERMIT NUMBER PERMIT APPROVED BYMATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICCATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED, FDRM C MUST BE COMPLETED FOR INSTALLATIONS.THISFORI SHOULD BE ACCOMPANIED BY A PLOT P 9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH' "RGROUND STORAGE TANK REGULApTITIONS ' FORM 8 (6-95) �� . — 4t/ 1