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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENT <br /> 'M 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: ' p <br /> �• /� E/Q(//CES 1AID Page of <br /> Facility Address: City: Inspection D e: <br /> .� // /� 17 <br /> FA#: � W nz PR#0 ;oz C3 Program e{nent: � <br /> Tank/Container Information CCTV' 33 <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 container product type. <br /> C44ank (2820) ❑ Containers(2821) #of Containers: TA#: L9,15-/ <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 1 A <br /> Total Capacity: _ / Sg�allons Product Type: /Pezo <br /> (pertankor emulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: DJ l ?Tlv� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2Product Type: Z2),95-:r G <br /> Total Capacity: / S b gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> IT (2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 prR Product Type: <br /> Total Capacity: �gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) Eq Containers (2821) #of Containers: 77 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: Lt/1?f"j£ D/ U <br /> Total Capacity: f blS gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: f TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) U <br /> 5 Product Type: /'7z f '�2 ae <br /> Total Capacity: s�gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: 3029 gallons <br /> Continents: <br /> EHD ImspectorReviewed Date: Entered Date:� <br /> G/ By Initial: `�.a.o. By Initial: ' J <br /> EHD 28-01 <br /> 01/16/08 <br />