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SAN JOAQUIN COUNTY A/D <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> 600 East Main Street, Stockton,CA 95202-3(,-- <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> a G T /L 0A//Z V ^ c 7 Page / of <br /> Facility dress: City: Inspection Date: 4/a/ <br /> 6 - G T R k /�aG - <br /> FA#: PR#: <br /> © o osz6�o� z 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 /> Clank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) �— e <br /> 1 Product Type: <br /> Total Capacity: yy gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Wank (2820) 13Containers (2821) #of Containers: TA#: 15,5-1 le p <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: _rod 0gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 9/Tank (2820) ❑ Containers (2821) #of Containers: TA#: L96-/ zeppb— <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 3 Product Type: ,�r-,Q� <br /> Total Capacity: gallons Install Date: <br /> (pertankor cumulative for containers by product type) <br /> C'Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) �N <br /> 4 Product Type: �-T <br /> Total Capacity: o gallons <br /> (per tank or cumulative for containers by product type) Install Date: ltil <br /> Tank (2820) ❑Containers (2821) #of Containers4r, TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 ,�5 Product Type: 0/ ,,/- <br /> Total Capacity: gallons ►+� <br /> Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Pager J 5 gallons I Total Capacity for Site: gallons <br /> Comments: <br /> qaj1W <br /> EHD Inspector: Reviewed Dat : Entered Date: <br /> C By Initial: �qBy a Initial: g <br /> EHD 28-01 <br /> 01/16/08 <br />