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SAN JOAQUIN COUNTY <br /> * ENVIRONMENTAL HEALTH DEPARTMEN <br /> 000 East Main Street, Stockton,CA 95202-30� <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 /> o G 1<.�Oh/ A 6!x.'6 :1 Page of <br /> Facility Address: City: Inspec i D <br /> z a y 02 T�� - 2-11 Is l <br /> FA#: PR#: Program Element: <br /> I o1 06 0 'z�3 <br /> Tank/Container Information <br /> Complete or all sites with cumulative aboveground storage of petroleum Z1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> It/Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: � 4 G <br /> Total Capacity: 1.60 gallons <br /> (pr tank or cumulative for containers by product type) Install Date: <br /> R/ <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM 6-1 7 102 <br /> (>250 gallons) (>55 gallons and 450 gallons) <br /> 2 Product Type: <br /> Total Capacity: S 0 a gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Ll Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) �- <br /> 3 Product Type: <br /> Total Capacity: Gtr gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> El Tank (2820) LR'Containers (2821) #of Containers: TA#: 6-1:Z L �' 7 <br /> (>250 gallons) (>55 gallons and 450 gallons) �- <br /> 4 /`� Product Type: (� <br /> Total Capacity: / "=S gallons <br /> (per tank or cumulative for containers y product type) Install Date: <br /> ❑ Tank(2820) containers (282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 -� Product Type: �� //S�GrO/ / `� <br /> Total Capacity: r.S gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page 2/ O 0 gallons Total Capacity for Site: gallons <br /> Comments: V <br /> 2 <br /> EHD Inspector: Reviewed Date: Entered �te <br /> By Initial: VV� By Initial <br /> EHD 28-01 ✓ �d <br /> 01/16/08 <br />