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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME. <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: • <br /> I AI 7—C2/�j /✓f� Page of <br /> Facility Address: t City: Inspection Date• <br /> FA#: PR#: Program Element: <br /> r�0i3 .S92 15-� '� <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >1320 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#: (9 <br /> (>250 gallons) (>55 gallons and<250 gallons) p� <br /> 1 Product Type: <br /> Total Capacity: ` gallons 1 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: ,S//p,3 7A <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 �� U � Product Type: 62,9 /�//'sl' <br /> Total Capacity: J gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> *ank(2820) Containers (2821) #of Containers: T #: 0±U&3 7 <br /> >250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: 2 U 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ank (2820) Containers (2821) #of Containers: / TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: '2.y U gallons <br /> (per tank or cumulative for containers by product type) Install Date: Q�.Qrv� <br /> V Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: 01 <br /> Total Capacity: ro 0 gallons <br /> (per tank or cumulative or containers by product type) Install Date: <br /> Total Capacity this Page: '2—4 Fj 6 gallons Total Capacity for Site: 77-0906 gallons <br /> Comments: Q *,j S- 'A�- k A lL�teO s o <br /> s 'e/ <br /> EHD Inspector: Reviewed Date: Entered Date: —/ <br /> . By Initial: V S.L��� By Initial: <br /> EHD 28-01 u <br /> 01/16/08 <br />