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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN" <br /> X600 East Main Street,Stockton,CA 95202-3022 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Na m e: x t .0w10 <br /> '(71 'K` Page of <br /> o <br /> Facility Address: City: Inspecda Date: <br /> 2 Ukrb 15T e_ P/ / 26 0 <br /> FA#: PR#: Program Element: <br /> 3373 P 6_'R 8'23 T z S <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 /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: S�y gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> �fank(2820) El Containers (2821) #of Containers: TA#- <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 2 Product Type: <br /> Total Capacity: 6 U 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: 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 (2821) #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. goo gallons Total Capacity for Site: S p o gallons <br /> Comments: <br /> <� Z0 Arm <br /> EHD Inspector: Reviewed ` , _'v Date: Entered Date: <br /> By Initial: � c1 By Initial: D <br /> EHD 28-01 A <br /> 01/16,/08 <br />