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. • STATE ID NUMBER 00000052077001 <br /> APPLICATION FOR PERMIT TO OPER UNDERGROUND STORAGE TANK <br /> 09 DELETE FROM FILE (NO FEE) <br /> ( ] 01 NEW PERMIT ( ) 05 RENEWED PERMIT 07 TANK CLOSED (NO SURCHARGE) <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ) <br /> I OWNER <br /> PURL C AGENCY ONLY <br /> NAME(CORPORATION,INOIVIDUAL OR PUBLIC AGENCY) 1 FED ( ) 02 STATE I 1 03 LOCAL <br /> HOLZ RUBBER CO. <br /> CITY STATE ZIP <br /> STREET ADDRESS I CA 95240 <br /> 1129 S. SACRAMENTO ST. <br /> II FACILITY <br /> ALER/ 0 MA4/SUPERVISOR <br /> FACILITY NAME <br /> HOLZ RUBBER CO. RE IMPENDERFER <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1129 S. SACRAMENTO ST. <br /> COUNTY ZIP <br /> CITY <br /> LOBI SAN JOAQUIN 95240 <br /> CITY STATE ZIP <br /> MAILINO ADDRESS CA 95241 <br /> P.O. BOX 109 LOBI <br /> EPHONEAREA CODE TYPE OF BUSINESS <br /> 7171 ( 1 01 GASOLINE STATION (X) 02 OTHER RUBBER PRODUCTS MANU <br /> NUMBER OF CONTAINERS <br /> 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 NIGHT$: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> SIMPENDERFER, FORREST 209-368-7171 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: -4409.- GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: f 1 Ol WASTE (X) 02 PRODUCT <br /> F. DOES <br /> 01THE <br /> UNLEADEDNf(1STORE <br /> REGULARVEHICLE <br /> 03FUEL <br /> PREMIUMWASTE <br /> �.X-Y 04OIL <br /> DIESEL 0( 1YES <br /> 05 WASTE IOL lI) 06YES <br /> CHECK <br /> APPROPRIATE BOX(ES): <br /> OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: I ) GAUGE ( 1 INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ( 1 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD f ) 08 BRONZE ( ] 09 COMPOSITE ( ) 10 NON-METALLIC <br /> [X) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 (10/18/85) <br />