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'i DEFARTMENW. <br /> 600 East Main Street, Stoci,-ton, CA 95202-3029 <br /> 7el�jvhone: (209)468-3420 Fzx: (209) 488-3433 Web: <br /> ABO'VEE.GROUINDEP PETROLE"UM STC--RA:NIS'UR-VEY FORM <br /> f <br /> Facility Narne: <br /> -7 <br /> C A ' I-Pa-e o'� <br /> OF d0616 Ilc,-,---'L41 <br /> Facility Address: City; p(I Inspection Dat <br /> A�4 7 491/1.0 . L <br /> yZ T <br /> FA Piogam Element; <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum -�-13)20 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) El Containers (2821) Fof Container's: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: <br /> Total Capacity, 0 gallons <br /> t7l <br /> (pet tank or cumulative for containers by product type) Install-Date: <br /> D. Tack (2820) ' El Containers (2821) #of Containers: TA9: <br /> ll .4m­Ilons) (>55 ZaEon-�?,nd,<250 gal!ons) <br /> 1>2 V. Product Type- <br /> 2 ! -.1 <br /> Total Capacity-, gallons - <br /> 4:� Install Date: <br /> (per tank-or cumulative for containers by preduct-ty <br /> pe) <br /> El Tank (1820) 0 Containers (2821) #,of Containers., TA-,: <br /> (,250 gallons) (>55 gallons and Q50 galIoas) <br /> 3 '-Product Type: <br /> Total Capacity.. gallons <br /> (per twit-twit-or cumulative for costa incz-5 by prociuct type) Install D a t 0: <br /> L <br /> i 1 FJ an (2820' 7— Contpiji-,rs (2821) Ag- <br /> #O'l <br /> >-,50 gallons) (--55 Zallons and<256 gallons) <br /> 1 4 "Product Type- <br /> t�1 Gall om <br /> (perLark C i.­ve fo ie-z;b�,produ,_t Oypt�'- <br /> conw.1 <br /> Z Cor!:Iainers: T <br /> (>260 gallons) '>ff-LH;ns--nd<250 gallails) <br /> T-y—pr;: <br /> Total Capaci�-,-- g <br /> L <br /> for cuntzincrs b:lprcd1_,rt <br /> far Sh. <br /> Y 0 <br /> .._w, / 00 <br /> 0 Mzl,3)D L.J. <br /> { _--__ �- /�-ria—��f��—��— <br /> EHD hispwor: Revicwed Date: Entered Date: <br /> G. By Initial: VA .a-� Oq By <br /> EED 23-01 <br />