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SAN JOAQunv COUNTY <br /> ENviRONMENTAL HEALTH DEPARTMEN <br /> %00900 East Main Street,Stockton,CA 95202-302'1 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> Page of <br /> Facility Address: City: Inspection Date: <br /> Guild k,*- �z)i 9-`:`-66 <br /> FA#: PR#: Program EI went: <br /> /67 <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 /> (� Tank(2820) ❑ Containers (2821) #of Containers: TAM /9,S/74,05"47 <br /> (>250 gallons) (>55 gallons and<250 gallons) -Q <br /> 1QT t <br /> 1 Product Type: V!J l 1 <br /> Total Capacity: �A gallons Install Date: <br /> (per tank or cumulative for containers by product type) — <br /> l9 Tank(2820) ❑ Containers (2821) #of Containers: TAM A.S17/h? <br /> (>250 gallons) (>55 gallons and 250 gallons) l �,"r <br /> � Product Type: µ� 011.E (J(�tf-C <br /> Total Capacity: �)50 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) EkContainers(2821) #of Containers: 3 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: B,1 <br /> Total Capacity: itI�� gallons <br /> (per tank or cumulative for containers by product type) Install Date: / -- <br /> ❑ Tank (2820) ® Containers (2821) #of Containers: 6 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: �3y gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: I A#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: I 7d gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Dater <br /> By Initial: By Initial: B <br /> EHD 28-01 <br /> 01/16/08 <br />