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SAN JOAQUIN COUNTY <br /> ` &ENVIRONMENTAL HEALTH DEPARTME ' <br /> 00 East Main Street,Stockton,CA 95202-Z'210 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> - <br /> Facility Name: <br /> r ;ArrTA //GI�IN�' �� PageOf <br /> Facility Address: City: Inspection Da <br /> JJ#-5 GV G A 1�vY STJT- 9s'z© S l� y <br /> FA#: PR#: Program Eleme t: <br /> 6 6 o5�� a IL 83 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> OP'fank(2820) ❑ Containers (2821) #of Containers: TAM Q,rj J 3 <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 1 3�p0 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> lank(2820) ❑ Containers(2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: yQ2 Q L /�, O 6 <br /> Total Capacity: ,�o T] gallons 'T � <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Q"Containers(282 1) #of Containers: TA# <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: q.GDr.I� <br /> Total Capacity: ST gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 0,(Containers(2821) #of Containers: TAM -J)9-,<P <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Tank(2820) ontainers (282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 �_ 27S Product Type: lX S ed o <br /> Total Cap <br /> � gallons <br /> (per tank or eumula r ontainers by product type) Install Date: <br /> Total Capacity this Page: S gallons Total Capacity for Site: � 22 c f GJ gallons <br /> Comments: <br /> a 5 &aaed <br /> EHD Inspector: Reviewed e: Entered Date <br /> Initial: By Initial: Ee <br /> rJ <br /> EHD 28-01 r <br /> 01/16/08 <br />