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SAN JOAQUIN COUNTY <br /> �./ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name- <br /> 630K/sCN /GANG,q - L G Page / of <br /> Facility Address: _ City: inspectio Date <br /> /ws LOD I 2 07 <br /> FA#: PR#: Program Element: <br /> 6'7 G3 2 U <br /> Tank/Container Information <br /> Comple for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Com Tete one box for each tank or each cumulative container product type. <br /> Tank(2820) ❑ Containers(2821) #of Containers: T #: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1Product Type: <br /> Total Capacity: SOD gallons <br /> (per tank or cumulative for containers by product type) Install Date: _-- -- <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) - - <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: _ - <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: 00 gallons Total Capacity for Site: gallons <br /> Comments: <br /> 3-Lo / 0 <br /> EHD Inspector: rn Reviewed ` Date: Entered Dale: <br /> r V a By Initial: �t�J a. 13'6 By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />