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SAN JOAQUIN COUNTY <br /> 4ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 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: . <br /> G Page I of <br /> ,l <br /> Facility Address: City: Inspection ate: <br /> 3-2, 6 i D .vT' Td'�,�-?':vim/ 7 0/0 <br /> FA#: fPR#: mPrograEleme : <br /> $ _ .. <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 t e. <br /> Tank(2820) El Containers (2821) #of Containers: , .TA#: <br /> ( 0 gallons) (>55 gallons and<250 gallons) / <br /> I Product.Type:.: 1'Lj m O� :U <br /> Total acity: Z gallons . <br /> (per tank or ulative for containers by product type) Install Date: <br /> Plf1 nk (282 ❑ Containers (282 1) #of Containers:' TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) Q 6 / , <br /> 2 Product Type: �J _ <br /> Total Capacity: Z gallons ` <br /> (per tank or cumulative for con ta ers by product type) Install Date: <br /> ElTank(2820) K'❑ Contain s (2821) #af Containers: TA#: <br /> (>250 gallons) (>55 gallons and 40 gallons) <br /> 3 Product.Type: 1Z k A �LVB` <br /> Total Capacity: ga ns <br /> (per tank or cumulative for containers by product type) Install'Date: <br /> ❑ Tank(2820) ❑ Containers (282.1) \Install <br /> ers: TA#: <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 4 .,.��. pe: JV ✓ <br /> Total Capacity. 0____gallonsk <br /> (per tank or currnilative for' .`nl by product type) :`" <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.. <br /> (per tank or cumulative for,containers by product type) Install Date: <br /> Total Capacity this Page: 2. D gallons Total Capacity' <br /> for Site: � Z d gallons <br /> Comments: <br /> �. Za L 9 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial -'t_.ej By Initial: G� <br /> l <br /> EHD2MI <br /> 01/16/08 <br /> .II <br />