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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENT <br /> "560 East Main Street, Stockton, CA 95202-302 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> /.S / or—/,1 S //L/C/ Page / of <br /> Facility Address: City: <br /> [aspectia Date: <br /> FA#: 1 S 7". /; /0 <br /> PR#' Program Element: <br /> 5- {D <br /> 2 3Q <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 /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA# <br /> (>250 gallons) (>55 gallons and X250 gallons) t <br /> 1 <br /> Total Capacity: / C7 O o gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> i <br /> El Tank(2820) ❑ Containers (2821) #of Containers: TA. /7c D <br /> (>250 gallons) (>55 gallons and<50 gallons) - <br /> 2 Product Type: n 2p <br /> Total Capacity: d o 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> �J Tank(2820) ❑ Containers (2821) #of Containers: TA#: 19,6-j`j fp <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: /. A S <br /> Total Capacity: 1660 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tatilc(2820) ❑ Containers (2821) #of Containers: `rA#• /7z <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: JJ <br /> Total Capacity: _5�n I!> gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> LJ4Ink/k(2820) ❑ Containers (2821) #of Containers: TA#: b <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: 16 1> gallons <br /> (per tank or emulative for containers by product type) Install Date: <br /> Total Capacity this Page: 4pocrgallons Total Capacity for Site: •! gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: r/ Entered Date: <br /> By Initial: ) I l_ By Initial <br /> EHD 28-01 l <br /> 01/16/08 <br />