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SAN JOAQUIN COUNTY <br />,NVIRONMENTAL HEALTH DEPARTMEN'i <br />600 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 Name: <br />EAIf/.0 L �FAl v�4gTom'2 C/4GL,E ZA,-o CD' <br />Page �of 3�- <br />Facility Address: City: <br />fjgo za CAGO <br />Inspectio iv Date: <br />"1 74 <br />FA #: <br />PR #: <br />D5�$S 3 <br />Program Element: <br />z., 8 3 <br />a <br />y Tank/Container Information <br />Co for all sites with cumulative aboveground storage of petroleum > 1320 gallons in tanks and containers over 55 gallons. <br />Comp ete one box for each tank or each cumulative container product type. <br />© Ta (2820) iners (2821) #of Containers: TAMf , <br />(>25 allons) >55 gallons <250 gallons) <br />p CjD Product T V 'f <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulativ i contain product type) <br />❑ Tank (2820) ®'Container 1) #of Containers: <br />2! <br />(>250 gallons) (>55 gat ouWjr<250 galboN 1, <br />Product Type: <br />Total Capacity: s <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) #of Contain s: )e TA#: � <br />(>250 gallons) (>3 I>fflProduct Type:Total <br />aproduct <br />Capacity:(per Date: <br />tank or cumulative for cInstall <br />❑ Tank (2820) LI Ontainers (2821) #of Containers—/— T #: <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />— Product Type: w^'t <br />Total Capacity gallons <br />Install Date: <br />(per tank cumulative for containers by product type) <br />--or <br />L1PI'ank (2820) ❑ Containers (2821) #of Containers: TAM /2�2 <br />5 <br />(>250 gallons) (>55 gallons and X250 gallons) <br />Product Type: <br />'p <br />Total Capacity: 0 gallons <br />` <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: ®' 3Z� gallons Total Capac �ty for Site: gallons <br />Comments: <br />1 X10 <br />— <br />�c <br />EHD Inspector: <br />C <br />Reviewed Date: <br />By Initial: i �,'�j 0 <br />Entered Date: <br />By Initial: �f <br />MN 'TGA v ll!Z7//-2 (Zvp I(I3D 1 (2 la I �tL— <br />EHD 28-01 / <br />01/16/08 <br />L <br />021 <br />