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SAN JOAQUIN COUNTY <br /> IDENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Weh:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> Page_ of� <br /> Facility Address: City: Inspec'on te- <br /> /PO6 vRr�n 1 S -rlk <br /> FA#: PR#: S� // �^ Program Element: <br /> 6 7 Z93 <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 /> It/Tank(2820) ❑ Containers (2821) #of Containers: .TA#: /9 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 2 2 0 0 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers;by product type) <br /> MteTank(2820) Containers(2821) #of Containers: TA#: 1 ci $ & <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: D/ L <br /> Total Capacity: Z �� gallons Install Date: <br /> tank or cumulative for containers by product type) <br /> SK/Tank nnt <br /> (2820) Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: i12'i'�ge9 1-14i G/ <br /> Total Capacity: Z �y gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> MerTank(2820) 43 Containers (2821) #of Containers: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 /, Product Type: p,, <br /> L <br /> Total Capacity: -2 Y'y gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> L9/Tank (2820) ❑ Containers (2821) #of Containers: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5Product Type: CIL CD✓V) C{ Cto r <br /> Total Capacity: 8'0� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 51,, Pgallons I Total Capacity for Site: SC D gallons <br /> Comments: <br /> / {o aao o Zla,,VL� CP 4f r (rPL'c PraO) <br /> � CGlaaz � 2�r o/ CArI�f2f3 yir> �. <br /> tk <br /> EHD Inspector: C Reviewed Date: d/ Entered 1 '^ Date: L <br /> t By Initial: .t t.Di Ey Initial: LIQ `/1y <br /> EHD 28-01 <br /> 01/16/08 <br />