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SAN JOAQUIN COUNTY h <br /> ENVIRONMENTAL HEALTH DEPARTMEN' �� <br /> 600 East Main Street,Stockton,CA 95202-302Y-- <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:,www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> C Ig L 5,� . 7'-� . G �i Page J of <br /> Facility Address: City: Inspecti D e• <br /> 2 r��vG 4- <br /> FA#: � � � � � -PR� � Pr��EleOent: <br /> Tank/Container In�atf . <br /> Complete for all sites with cumulative aboveground storage of petroleum z allon 'n tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumul Ive container oduct e. <br /> ❑ Tank (2820) eContainers (2821) #of Contain A#: <br /> (>250 gallons) (>55 gallons and<250 gallons) r <br /> Total Capacity: gallons. Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Wtontainers(2821) #of Containers: 3 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) . <br /> 2 "' / Product Type:: <br /> Total Capacity: /6/f gallons <br /> (per tank or cumulative for containers by product type) .Install Date' <br /> ElTank(2820) Lz!'Containers'(2821) #of Containers: E TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: Q gallons - <br /> (per tank or cumulative for containers by product type) Install Date- <br /> M w <br /> y ❑ Tank(28 0) .. Containers'(2821) #of Contai ers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 _ Product Typ <br /> Total Capacity: ,2Jr49 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 /> c ' <br /> i Total Capacity this Page: gallons Total Capacity for Site: Q� gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: EnteredDater <br /> ✓ By Initial: 01.-I,.Ott By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br /> :p- <br />