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SAN JOAQUIN COUNTY <br /> kENvIRONMENTAL HEALTH DEPARTMEN <br /> 00 East Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: Page / of <br /> GiFN�pN� FARII s <br /> Facility Address: City: <br /> InspectnFYJDeate: <br /> I L / �� <br /> o <br /> FAN / <br /> D�+ PR#:0 `I dD Frog-z (J n <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: D57� 7Ze /�I <br /> (>250 gallons) (>55 gallons and<250 gallons) + n <br /> I Product Type: �. <br /> Total Capacity: r7O © gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: Z le'ZD <br /> (>250 gallons) (>55 gallons and 250 gallons) <br /> 2 Product Type: — <br /> Total Capacity: ) 0 O 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) U?6ontainers (2821) #of Containers: / TA#: 95-17(po'Z( <br /> (>250 gallons) (>55 gallons and 250 gallons) <br /> 3 Product Type: /y,/ P94 r. <br /> Total Capacity: 'S gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Z Containers (2821) #of Containers: L TA#: �6_/ 7(o 3a1- <br /> (>250 gallons) (>55 gallons and 250 gallons) <br /> 4 Product Type: /,1/.41.-I-TI�' 04 , <br /> Total Capacity: //0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank(2820) LN'Containers (2821) #of Containers: f TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: Z Z- D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: g BS gallons <br /> Comments: <br /> EHD Inspector: /� Reviewed Date: Entered Dale: <br /> '�dJv By Initial: -dr-Q BylnitiaL <br /> EHD 28-01 G N VV <br /> 01/l6/08 <br />