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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN" <br /> "i00 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 Naa�l/ M ` A/✓J7 0j� Page Of <br /> Facility Ad/dress:/ City: Inspection Dat <br /> G,� p/ARCY �'/Clvy LsiTHRof 10 11- <br /> og <br /> FA#: PR#: Program Eletstent: <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 /> Com fete one box for each tank or each cumulative container product <br /> ❑ Tank(2820) Ertontainers (2821) #of Containers: _ TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: —Z'1z D D!Z 0/ �— <br /> Total Capacity: 2 21C7 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ElTank(2820) MZntainers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: Z!, D — 0� <br /> Total Capacity: Z ZO gallons <br /> (per tank 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 /> 3 Product Type: <br /> Total Capacity: gallons Install Date: L <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) ❑ Containers(282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: - <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<50 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: t f C7 gallons Total Capacity for Site: Lf gallons <br /> Comment• <br /> EHD Inspector Reviewed Date: -/ Entered Date: <br /> C• By Initial: vlrjBy Initial: lB O <br /> EHD2"l <br /> 01/16/08 <br />