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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN'' <br /> - o00 East Main Street, Stockton,CA 95202-302,j <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name <br /> / � G S 7—& <br /> �� Page / of � <br /> Facility Address: / City: Inspectio Date: <br /> -- w 13 <br /> FA#: R#: Program Element: <br /> 0 a o� �Lr�TOf3 Lf I <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum>_1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative ontainer producttype. <br /> Tank 2820 ontainers 2821 v _ I <br /> Tank (2820) ( ) # f Co tairsG. - .'T <br /> (>250 gallons) 5 ns d T gall :. <br /> 1 r '' `'T ype: <br /> Total Capacity: 1pp .gaHo <br /> (per tank or cum�laiye4p�;centaitis y product type) ~I Sfal�late: <br /> Tank 2820 ❑ Container 821 ✓✓ , <br /> ( ) ) #�of.�o tainers• JA#:-�5 /• oZ <br /> (>250 gallons) (>55 gallons and 50 galla_ As) <br /> 2 "=�` � 1 � red "I"ype: <br /> Total Capacity: __...'albse <br /> (per tank or cumulativpfcu-c�ersv�t�l[r by product type) <br /> StldlrDate: <br /> U Tank (2820) ❑ Containers (2821) #of Containers: TA#: ATI J/9�� <br /> (>250 gallons) (>55 gallons and<250 gallons) /'� <br /> 3 Product Type: �j 0 �D 2 d� (/ <br /> Total Capacity: g D-fl gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ff Tank(2820) ❑ Contain s 2821) #of ntaine'fs�_ Tk#: � r � <br /> (>250 gallons) (>55 gallons and �5�0�:gajsr <br /> Total Capacity: 0. <br /> •_•-- <br /> (der tank or cumulative for co>�by"j�t'�d'uct type) Anstall Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: J ;t gallons Total Capacity for Site: 0� ' ' gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Dat <br /> V-4ft / <br /> ( By Initial: ^l. V%" By Initial: Il <br /> n <br /> EHD 28-01 <br /> 01/16/08 <br />