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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 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: .v <br /> © Ol.E r'- /1/S Page / of <br /> Facility Address: City: tnspectlon ate: <br /> FA#: PR#: Program lemegt: <br /> Z 2 90Sa�tDa 2 � 3 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product <br /> IT(Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) �) <br /> 1 Product Type: �Yfjj s d <br /> Total Capacity: 5o ©0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM IP 62 W <br /> (>250 gallons) (>55 gallons and<250 gallons) �"" <br /> 2 Product Type: fT— 4 S <br /> Total Capacity: S000 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAMC <br /> (>250 gallons) (>55 gallons and<250 gallons) r <br /> 3 Product Type: <br /> Total Capacity: 'ZO dD gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: 'W: a6-1`Z le 70 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: �0 b gallons <br /> (per tank or cumulative for containers by prodttat type) Install Date: <br /> UT" <br /> "tank(2820) ❑ Containers (2821) #of Containers: TAM, l 77 42:Z 1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: 60d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 7i 5Q t'7 gallons Total Capacity for Site: 0 00 gallons <br /> Comments: <br /> EHD Inspector. Reviewed Date: Entered Date: <br /> By Initial: (-�'�.o By Initiater�- <br /> EHD 28-01 <br /> 01/16/08 <br />