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S A N LIQ.,' air C-O%UNTY <br /> t. <br /> Et\IY iRC)iN YIEiJ i Ai i�EALTR Dli'P 1^cTYIr.Ilw- <br /> a C t i 4 2-^ 9 <br /> . <br /> 600;=as_i�ail.Street, Stecictor_; CA 9520 X02_ <br /> 7 eievhoue: (209)455-34.20Fa-k: (209)468-3433 ji✓eb.www.sjSov.org/eM <br /> BO-1iEG110UE) PEAR-0LFUM S`f0EAGE FROG-'INI- SURVE Y 11-0Rt I � <br /> Facility Name: <br /> I&V EAl -� / T�e4 S '/� /�/S Tit 1` gage ° <br /> Facility Address' City: Inspection matte:, r1 <br /> x FA ff: � Ja � PR�: + � Prog� e�t® <br /> S <br /> Tank./Container Inforination <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1320 gallons in tanks and containers over 55 galloris. <br /> Complete one box for each tank or each cumulative container product type. <br /> a <br /> D--1 ank (2820) ❑ Containers (2$21.)- #of Containers: TA#: <br /> (>250 gallons) (155 gallons and<250 gallons) <br /> 1 Product Type: - <br /> Total Capacity: S-C tS gallons lnstail Date: <br /> (per tank or cumulative for containers by product type). — <br /> � I <br /> C Far- (2820) C Containers (2821) . #or Containers. T A#• <br /> >250 gall mE,, (>5:gallons�.ad�2S0 ga!!o^s) c3 <br /> ,2 v <br /> Prodact T �e: <br /> a I =` i <br /> 'r Intal Ca. ac'. • O P/ -gallons Install Date: <br /> - J. – <br /> (per tan;<or cumulative for containers by product type) <br /> Ll Tank (2820) C1ontainers (2521} sof Containers: TAI'- <br /> (1250 <br /> A#:(1250 gallons) (>55 gal Ions and<20 gallons) <br /> Product Type: - <br /> i utas Capacity. T l ID C: <br /> iil5tc«z eee <br /> a I' (pir tan cr cumulative for contains,-,byproduct type) 1 <br /> r ;, <br /> + •' f r 1 • ; <br /> rJl�ralnarc. l l <br /> v <br /> (>%SG gallons} (>55 Gallons and<250 gailons) <br /> 7 Fypp { <br /> ,I oral ' 1�U!r`r' � � �alln'1� Laiy r;syr, <br /> ❑ Taia_ C�V} ❑ viiia w �L-21) poi containers: T h. —_ <br /> (>2 j0 galls) y {>55 o�17cns and<250 gallons) _ <br /> s <br /> i s"Zge: / / V N .� .klszi375 .r !-1�'1�.:-r::_�4A'L".7±ii <br /> 7 <br /> 71 <br /> 1 ; <br /> z,"O l <br /> EHD Inspector: ReJiewed Date: EnteredDate �..� <br /> By Initial: k4 .01 By 4�itial: /p( <br /> E:iD 25-01 <br /> 0 17W08 <br />