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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTMEi <br /> 600 East Main Street,Stockton,CA 95202-3 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> 11 1�11 1111 1,11111 101 1111f Page of <br /> Facility dress: City: Inspection ate: <br /> zz r z 6 <br /> FA#: ©O 0 Z PR#:8 �/ O Program Element:X040 0 28fv <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 <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: (&,5/[P nj(Qt) <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: �� S <br /> Total Capacity: {� 066 gallons Install Date: <br /> —/(per tank or cumulative for containers by product type) <br /> L3 Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 1060 Product Type: <br /> Total Capacity: j4dpvWj0 gallons Install Date: <br /> (per tank or emulative for containers by product type) <br /> Tank(2820) ❑ Containers (2821) #of Containers: A#: 0g l (p 3 (p7 <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 3 Product Type: <br /> Total Capacity: 3 p p-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: Z J [p'3 Lea <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: �y <br /> Total Capacity: 17nII-a gallons <br /> (per tank or cumulative for containers by product type) Install Date: �" p <br /> Tank(2820) El Containers (2821) #of Containers: TA#: 4X34— <br /> 5 Product T <br /> (>250 gallons) (>55 gallons and<250 gallons) Type: �X©� 3^ o` G <br /> Total Capacity: ? 00 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons I Total Capacity for Site: gallons <br /> Comments: <br /> EHD inspector: Reviewed Date: d Entered Date: <br /> C, ✓` By Initial: 5 y�^ o By Initial: <br /> EHD 28-0I SCJ <br /> 01/l6/08 <br />