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SAN JOAQUIN COUNTY <br /> WIRONMENTAL HEALTH DEPARTMENT <br /> '"6 East Main Street,Stockton,CA 95202-302~ <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 /> CG ( i �0...1� �j Page of <br /> Facility Address: I I City: / Inspection Date: / <br /> Giy qrt C)AA . �/ 0� O O—/ <br /> FA#: I PR#: Program lement: <br /> eR C">O"Z140 1 O 572--2— <br /> Tank/Container <br /> 72--2 .Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: ZO -e>o o gallons <br /> (per tank or cumulative for co ersby product type) Install Date: LA+ <br /> ❑ Tank (2820) containers (2821) #of Containers: -_73 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 33 O gallons <br /> (per tank or cumulative for containers by product type) Install Date: Ur <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 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 /> 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 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Zcr> gallons Total Capacity for Site: 20 33o gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />