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SAN JOAQUIN COUNTY <br /> C.NVIRONMENTAL HEALTH DEPARTMENT <br /> X00 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 e: I <br /> NaLA / Ro G1 r Gp " SToeQrl DK AIN /t'1" 3 Page--LOf / <br /> Facility Address: City: Inspectlo Date: <br /> 0o corp c . G2t-r-k wy &9f&Po z 6g <br /> FA#: PR#: ProgrAm EI e <br /> e a O6-07 86� -2- � <br /> Tank/Container Information <br /> Complete f all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Com lete one box for each tank or each cumulative container product <br /> link(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> I _r> <br /> � 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: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons Mall Date: <br /> (per tank or emulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Mall Date: <br /> (per tank or emulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons Mall Date: <br /> (per tank or cumulative for containers by product type) - <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <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: 0 gallons Total Capacity for Site: 5 D gallons <br /> Comments: <br /> EHD Inspccmr: Reviewed te: Entered Date <br /> By Initial: -atryo D By Initial: q �? <br /> EUD28-01 VVV�" <br /> 01/16/08 <br />