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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENO 6013 East Main Street,Stockton,CA 95202-107 ..:1 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: G o G g �.-C 5 U Page of Facility Addres City: inspec ion ate: ^ �� ^ R r, C�/J Jl FA#: PR#: Progra Elem nt: � oi3.S�z- o � Z7 /70 2 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. 1-1 Complete one box for each tank or each cumulative container product type. 134�ank (2820) ❑ Containers (2821) #of Containers: e TA#: I'D (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: /-/D & 0 gallons Install Date: (per tank or cumulative for containers by product type) Tank(2820) tainers (2821) #of Containers: TA#: 0 sJ (>250 gallons) >55 gallon d<250 gallons) 2 ��(� Product Type: Total Capacity: gallons (per tank or cumulative for ers by product type) Install Date: anlc 820) o iners (2821) #of Containers: TA#: ff�g (> ns) (> gallgns <250 gallons) i- 41 3 ` ' Product Type: Total Capacity: gallons or cumulative for con y mers by type) Install Date: a ~ 820) rs (2821) #of Containers: TA#. (> ns) (>55 gall s an 0 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Wank(2820) `C,�Containers (2821) #of Containers: _ TA#: f >250 gallons) ( 55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: f gallons Total Capacity for Site: gallons Co nts: . EHD inspector: Reviewed at : Entered Date: By Initial: L By Initial: EHD 28-01 ` 1 g ' 01/16/08