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SAN JOAQUIN COUNTY <br /> ,,.e ENviRONMENTAL HEALTH DEPARTMEN*,,rs- <br /> 600 East Main Street, Stockton,CA 95202-3029 <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 /> �.r.• r%, i _ o6z Page / of <br /> Facility Aadres-Z s. 7� r T Ls city.. ' ? Inspection Date (w �/ / <br /> FA#: PR#: Program Element: <br /> CC) 17- Ile o 5-/ (?,3 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> a t ❑ Containers(2821) #of Containers: TA#: B6-4( �1 <br /> (>250 gallons) ns and<250 gallons) <br /> I Product Type: l9,�e�i <br /> Total Capacity: /0, 0 0 0 gal 0 <br /> (per tank or cumulative for containers by product type) 11 Date: <br /> L9'Tank(2820) ❑ Containers (2821) #of Containers: t #: 126-1 ll�'35og <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons Install Date: FA T <br /> (per tank or cumulative for oslmain_ers by product type) <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#• O <br /> I>250 gallons) (>55 gallons and<250 gallons) <br /> y� ,� 2>� Product Type: Fn2 aq �t <br /> Total Capacity: �b4 gallons stall Date: <br /> (per tank m cumulative for containers by product type) <br /> Tank(2820) ❑ Containers(2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: nt <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ffiTank(2820) ❑ Containers (2821) #of Containers: _r TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> ZSR Product Type: 711-lC (dSr-� ©t I <br /> Total Capacity: C,7 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: / L7 gallons <br /> Comments: <br /> � i✓ <br /> e3 [ <br /> ERD Inspector: Reviewed Date: Entered t <br /> G' / By Initial: By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />