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1 SAN JOAQUIN COUNTY <br /> `/ENVIRONMENTAL HEALTH DEPARTMENt„r <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 /> G C�/r�/T �GOI�Ol C`�NW Page / of � <br /> Facility Address: �� City: Inspection Date: <br /> //a O <br /> FA#: PR#: Progralia Etc t: <br /> 1=,q o ( 121 O oma o? <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 /> ET'Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 7 w 0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> � 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 (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) - <br /> 4 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 /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per utnk or cumulative for containers by product type) - <br /> Total Capacity this Page: 7F6 gallons Total Capacity for Site: gallons <br /> Comments: y2 t/E/2/17'0/L <br /> 1 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: wr� (t•1)1.0 By Initial: O <br /> EHD2"I <br /> 01/16/08 <br />