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SAN JOAQUIN COUNTY <br /> 'ENVIRONMENTAL HEALTH DEPARTMENT <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 /> G'ranlXe Page / of <br /> Facility Address: City: Inspection D te: <br /> �3ogo9 s. Tra Sited. q /4- ro <br /> FA#: 9�7q PR# �� Program Element: <br /> � aa&52 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks" and containers«« <br /> / <br /> Complete one box for each tank or each cumulative container product type. <br /> 2 Tank (2820) ❑ Containers (2821) #of Containers: TA#: D,h l 9/D 9(�2 <br /> 1 Total Capacity: /c� gallons Product Type P�12 r <br /> (per tank or cumulative for containers by product type) Install Date: <br /> &?/Tank (2820) ❑ Containers (2821) #of Containers: TAM OS/ (o2(9 $ <br /> 2 Product Type�P�V <br /> Total Capacity: /Q, eOz gallons <br /> (per tank or cumulative for�w tainers byproduct type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> Total Capacity this Page: (Q / 2 gallons Total Capacity for Site:!o. /2S gallons <br /> Comments: <br /> EHD Inspe ReviewedDate: Entered Date: <br /> By Initial: VAJ5 •'L`�-t4 By Initial: -�b p <br /> "Above rou storage tank means a tank that has the capacity to store 55 gallons or more of petroleu . <br /> ""Conte means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> /08 <br /> 09/12/Oe AST SURVEY FORM <br />