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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 'T60 East Main Street,Stockton,CA 95202-3029 "f <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> Page of <br /> Facility Address: City Inspection a <br /> '39 61 z-5 Mlo5 IQON(Y Z'©D/ /7- c te©S <br /> FA#: PR#: Program Element: <br /> 1 D5agg4?a -Z8 �La <br /> Tank/Container Information <br /> Completepr all sites with cumulative aboveground storage of petroleum 2t1320 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<250 gallons) <br /> 1 Product Type: f7Aa <br /> Total Capacity: _� gallons Install Date: <br /> (per or cumulative m contamers by product type) - <br /> Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: ��—A.S � <br /> Total Capacity: 3 OY9 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: TA4: <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(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: VV gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: /^c; <br /> By Initial: ]_.��.01� By Initial <br /> EHD 28-01 <br /> 01/16/08 <br />