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SAN JOAQUIN COUNTY <br /> E00NVIRONMENTAL HEALTH DEPARTME <br /> East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY <br /> Facility Name: <br /> �iV T p 2`A 7 0 Page 2� of <br /> Facility Address: City: Inspec[io <br /> 11 <br /> FA#: PR#: Program Element: <br /> -311 a 3 <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#: _Qc5j 0 <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 1 I � Product Type: <br /> Total Capacity: O 1 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> I�] Tank(2820) ❑ Containers (2821) #of Containers: TA#: �/ 7B� <br /> ll(>25 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 2 J V gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers(2821) #of Containers: TA#: 19, <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: pl e <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: ��/ [ 7DoZ <br /> (>250 gallons) (>ss gallons and Q50 gallons) <br /> 4 Product Type: &(f4-rc7/ <br /> Total Capacity: / 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 /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> kT <br /> 7 <br /> EHD Inspector. 1 Reviewed Date: Entered Date: _ <br /> By Initial: By Initial: Q ,! <br /> EHD 28-01 d <br /> 01/16/08 <br />