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SAN JOAQUIN COUNTY _ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �00 East Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Far.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> D,6U-nt,Jr, 136L <br /> 05' F MI N Page of <br /> Facility Address: City: Inspection ate: <br /> a,a o G�G�" lv'xc <br /> FA#: PR#: ProgroElement: <br /> 7 -5a3 1 z 36 <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 /> EV'Tank(2820) ❑ Containers (2821) #of Containers: TA#: 8517 �v2 <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 1 Product Type: <br /> Total Capacity: / 0 or) gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: in3 <br /> 2 <br /> (>250 gallons) (>55 gallons and<50 gallons) Type: <br /> �� `� T <br /> Product T e• <br /> Total Capacity: So (1 gallons Install Date: <br /> (per or cumulative for containers by product type) <br /> Tank(2820) ❑ Containers(2821) #of Containers: TA#$� b5/"]to"I4 <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 3 Product Type: <br /> Total Capacity: ii('31_[J_(L gallons <br /> (per tack or curmilativii 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 <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 /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Z,5-04 gallons Total Capacity for Site: Z..1"a d gallons <br /> Comments: <br /> EHD Inspa[or. Reviewed Date: Entered Date: <br /> l.i By Initial: (a ,�• By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />