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SAN JOAQUIN COUNTY <br /> 1./ENVIRONMENTAL HEALTH DEPARTMEN-�,,/ <br /> 600 East Main Street, Stockton,CA 95202-302f <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name- 1 l S 2//O A 'Te U GK//`1� I A C/ Page of <br /> Facility Address: City: Inspecti Data <br /> 1 '7 A c Ac n�� <br /> =6;n <br /> FA#: Program Element: <br /> 3 8CA CD 2 $ <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 /> Com to one box for each tank or each cumulative container product type. <br /> ❑ Tank (2820) 1116ontainers (2821) #of Containers: —./— TA#: ---- <br /> (>250 <br /> _(>250 gallons) (>55 gallons and<250 gallons) <br /> 1Product Type: � 42 12 r v <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) - <br /> ❑ Tank (2820) ontainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) - <br /> 2 Product Type- <br /> Total Capacity: Z S-0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) , <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> q Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> g Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) 3 <br /> Total Capacity this Page: 0 gallons Total Capacity for Site: 3 d ,�� gallons t <br /> Comments: <br /> I <br /> EHD Inspector. Reviewed t Date: Entered Date: <br /> L' By Initial: ' , sv' 0/a'�. By Initial: 0D <br /> EHD 28-01 <br /> 01/16/08 <br />