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SAN JOAQUIN COUNTY <br /> . <br /> {. ENVIRONMENTAL HEALTH DEPARTMEN"i <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: G L Page of "f <br /> A11 A Al I C GSC w <br /> City: 'Inspection��t A <br /> Facility Address: / CJff <br /> d Program El e at, - <br /> FA#: PR#: v <br /> Job l <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum ?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: n <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 /> 2 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 /> 3 Product Type: <br /> Total Capacity: gallons f <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 /> F <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 /> Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: (f f�� gallons Total Capacity for Site: gallons <br /> Comments: <br /> f , <br /> EHD inspector: Reviewed Date: j Entered D e: <br /> By Initial: <br /> EHD 2"1 <br /> 01/16/08 - <br />