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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 Nam <br /> J-kIaz v- Ck—"dh op-z7,2e • Page / of Z <br /> Facility Address: City: Inspe tion Da <br /> 5�o S• �� J9 cz� c�ft�r� j2s �r q <br /> FA#: PR M Program Element: <br /> /19Lo5FS 0528/3 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks" and containers" <br /> Complete one box for each tank or each cumulative container product type.- <br /> -- <br /> [Tank (2820) ❑ Containers (2821) ---#of Containerv--�TA#: ,5-oO <br /> 1 Total Capacity: Product Type: <br /> -�-�-�f--gallons <br /> jper tank or cumulative for containers by product type <br /> Install Date: �1 <br /> Tank (2820) El Containers (2821) <br /> #of Containers: TA#: <br /> 2 Total Capacity: 2 D 0 gallons Product Type: /12 O tD ` 07-1 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: 2D D gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> 19 Tank (2820) //❑ Containers (2821) #of Containers: TA,/#: <br /> 4 Total Capacity: T 0 0 gallons Product Type: jjs- �i/ O/ l <br /> (per tank or cumulative for containers by producttype) Install Date: <br /> ❑ Tank (2820) Xcontainers (2821) #of Containers: I- - TA#: ,9 aDl lv f <br /> 5 Total Capacity: gallons Product Type: /1/10 f IJ Q/ <br /> (per tank or cumulative forcontainers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: �. � (�J gallons <br /> Comments: <br /> 1.14 y AR 11 1142 JL� <br /> -N l 1,!128 /YI CL/7-P.vl � a <br /> � <br /> EHDact IReviewed- Date: Entered Date: `/ <br /> By Initial: �'� LA\ 1 `, 8y Initial: er ,t/ I / <br /> "A v round storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. [ <br /> "C ntainer means a storage device designed to be moved when full. <br /> EHDAST SURVEY FORM <br /> 09/12/08108 <br />