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SAN JOAQUIN COUNTY <br /> 3NVIRONMENTAL HEALTH DEPARTMENT <br /> ""60 East Main Street, Stockton,CA 95202-3020-k <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 /> rAAC- Y Page of <br /> Facility Address: City: InspeD <br /> 3 no To �y 1n c tit at 06' <br /> FA#: � P�5 O �C.O� Prom ent: D <br /> 001036 <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 /> (flank (2820) ❑ Containers (2821) #of Containers: TAM 1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> I � Product Type: J [> <br /> Total Capacity: �D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> fjl�ank(2820) ❑t Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: / <br /> Total Capacity: _� gallons <br /> (per rank or cumulative r ccnta rs by product type) <br /> Install Date: _ <br /> ❑ Tank(2820) Containers(2821) #of Containers: T _ <br /> (>250 gallons) (>55 gallons and<250 gallons) G <br /> 3 Product Type: <br /> Total Capacity: 7i2V gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per ma or cumulative for containers by product type) Install Date' _ <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 Install Date: <br /> (per tank or cumulative for containers by product type) -- -- <br /> Total Capacity this Page: j> Q gallons Total Capacity for Site: QD gallons <br /> Comments: <br /> EHD Inspector: Reviewed ' -�I Date: �( Entered Da <br /> By Initial: W" n �' eL By Initial: <br /> EHD 28-0I VV <br /> 0l/16/08 <br />