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SAN JOAQUIN COUNTY <br /> -,NVIRONMENTALHEALTH DEPARTMENT <br /> '-Bft East Main Street, Stockton,CA 95202-302 -4- <br /> Telephone. (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Na A/ Y'AI&ID W . Page�_of <br /> Facility Address: City: Inspectio Date• <br /> 6803 A ��x � L�rr El J ` ° <br /> FA#: PR#: Progre�Lm Eleptegt:•.n <br /> 8 LIGV <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 /> Complete one box for each tank or each cumulative container product <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 1 Product Type: <br /> Total Capacity: /000 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 /> 2 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 /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: C, p v gallons Total Capacity for Site: JQ U (') gallons <br /> Comments: <br /> Ll3Zo /lOW <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: / By Initial <br /> EHD 28-01 <br /> 01/16/08 <br />