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}� { SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEP%moL <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: 7-0 f f, Ix/V/1( Page t of <br /> f <br /> City: / Inspection D te- �lg <br /> Facility Address: �� � � � � +� /,1 Q 1GOLD <br /> PR#: Pror <br /> FA#: <br /> 49J It- <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum ;>-1320 gallons in tattles 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: 1 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 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 /> 2 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 /> 3 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 /> � Product Type: <br /> Total Capacity: ballons Install Date: <br /> (per tank or cumulative for containers by product t}pe) <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 tank or cumulative for containers by product type) <br /> Total Capacity this Page. ( gallons Total Capacity for Site: gallons <br /> Comments: <br /> I <br /> 2-0 //fes IVf <br /> I <br /> EHD Inspector: Reviewed Date: 0 Entered ter <br /> By initial; 1�,'J,�• By Initial: <br /> EHD 28-01 <br /> 0l/16108 <br />