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• • STATE 10 NUMBER 00000052077003 <br /> APPLICATION FOR PERMIT TO OPERAT GROUND STORAGE TANK <br /> l l 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 09 DELETE FROM FILE (NO FEEL <br /> i ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARG ) <br />[ OWNER A/A� <br /> NAME(CORPORATION,INDIVIOUAL OR PUBLIC AGENCY) BL ly AGENCY ONLY <br /> HOLZ RUBBER CO. ( OM1 FED ( 102 STATE f ) 03 LOCAL <br /> STREET ADDRESS CIT STATE ZIP <br /> 1129 S. SACRAMENTO ST. OD CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> HOLZ RUBBER CO. FORREST SIMPENDERFER <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1129 S. SACRAMENTO ST. <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 109 LODI CA 95241 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-368-7171 ( ) 01 GASOLINE STATION (X) 02 OTHER RUBBER PRODUCTS MANU <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 4 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME( LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> SIMPENOERFER, FORREST 209-368-7171 SAME - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK f ) 04 OTHER: CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (Xl UNKNOWN <br /> D. CONTAINER CAPACITY: 500 GALLONS ( l UNKNOWN E. DOES THE CONTAINER STORE: ( ] 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( l GAUGE ( ) INCHES ( 1 CM (X) UNKNOWN <br /> B. ( l 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( 7 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> 0. ( ) 01 CARBON STEEL ( l 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( l 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM f 1 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE t ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />