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SAN JOAQUIN COUNTY <br /> .,,JVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 y <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 /> W, T 0 6R o S Page_�of <br /> Facility Address: Ret City: Inspection Rate- <br /> * IV ALAPIN15 <br /> FA#: PR#: Prograelement-' 0 <br /> 2Z1 05;2"3 2 3 <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 type. <br /> ank(2820) ❑ Containers (2821) #of Containers: TA#: `Z 5 <br /> (>250 gallons) (>55 gallons and<250 gallons) b <br /> 1 Product Type: �A S �j <br /> Total Capacity: �ZD O A gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 1;YTank(2820) ❑ Containers (2821) #of Containers: TA#: d5 / -75 7,± <br /> 2 Product T <br /> (>250 gallons) (>55 gallons and<250 gallons) Type: tf--A 00 <br /> /2 <br /> Total Capacity: 2 O 0 D 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 /> 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 <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: 0 0 0 gallons Total Capacity for Site: ��6 gallons <br /> Comments: <br /> EHD Inspector: Reviewed ` Date: Entered Date: <br /> By Initial: 1 s tAl By Initial: / <br /> EHD 28-01 VVV""'"--- (! <br /> 01/16/08 <br />