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SAN JOAQUIN COUNTY <br /> . ENVIRONMENTAL HEALTH DEPARTMENT <br /> 'a600 East Main Street,Stockton,CA 95202-302 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: I <br /> G!T D I- G TF 7- rg L/NC o r/ Page of <br /> Facility Address: City: Inspect a Date• ,[) <br /> D f5I O N bar=GL p (xJ <br /> FA#: PR#: Progrard Element: <br /> D Z2,r7 2 <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 <br /> ank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallc as and 250 gallons) n <br /> 1 Product Type: Li <br /> Total Capacity: /Ogallons Install Date: <br /> (per tank or cumutative for containers by product type) - - <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <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 Mall 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 Mall 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 /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) - <br /> Total Capacity this Page: /0 O gallons Total Capacity for Site: J tq d gallons <br /> Comments: <br /> G UN <br /> EHD Inspector: ,y Reviewed VA Date: Entered Date: C <br /> V' <br /> By Initial: (�.'.t6A`� By initial: <br /> EHD2"1 <br /> 01/16/08 <br />