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• • STATE ID NUMBER 00000052077002 <br /> APPLICATION FOR PERMIT TO OP ERGROUND STORAG TANK <br /> I ) 01 NEW PERMIT ( l 05 RENEWED PERMIT TANK CLOSED 09 DELETE FROM FILE (NO FEE) <br /> f ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PU LIC AGENCY ONLY <br /> HOLZ RUBBER CO. 01 FED ( ) 02 STATE ( ] 03 LOCAL <br /> STREET ADDRESS STATE ZIP <br /> 1129 S. SACRAMENTO ST. CA 95240 <br /> II FACILITY / <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> HOLZ RUBBER CO. FORREST SIMPENOERFER <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1129 S. SACRAMENTO ST. <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> P.O. BOX 109 LODZ CA 95241 <br /> PHONE W/AP.EA CODE TYPE OF BUSINESS <br /> 209-368-7171 ( ) 01 GASOLINE STATION fX) 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 /> SIMPENDERFER, FORREST 209-368-7171 SAME - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 250 GALLONS ( 7 UNKNOWN E.. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES (X) 02 NO IF YES CHECK APPROPRIATE BOXf ES): <br /> f 1 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL f l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE t ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED f ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( l 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD f 1 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (30/18/85) PAGE 1 <br />