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SAN JOAQUIN COUNTY <br /> I..,NV IRONMENTAL HEALTH DEPARTMENT' <br /> 600 East Main Street,Stockton,CA 95202-3029usrt <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: t / d Page / Of <br /> G / fNR C d <br /> Facility Address: City: Inspection ate: <br /> -?,Z/ 1111214 <br /> FA#; r, PR#: Program Element: <br /> S3Gg '2_2 30 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> J <br /> Complete one box for each tank or each cumulative container product e. <br /> LTJ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (r�Z 57&7 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: �a�� <br /> Total Capacity: { ('/ gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 17J Tank(2820) ❑ Containers (2821) #of Containers: TA#: /9651 75'leS <br /> (>250 gallons) (>55 gallons and<250 gallons) ^ <br /> 2 Product Type: 6�& <br /> Total Capacity: ) O 00 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#:�/ 76Y4 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: _6- A5 $� <br /> Total Capacity: / 00o gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: 3 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: /Yldz(f� D1 <br /> Total Capacity: ai C S gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: 3 TA#: Oe51-7J`7 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: 64STf () ( y <br /> Total Capacity: / 6 S gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 0 gallons Total Capacity for Site: -7330 gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: VA I I.P.0 By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />