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SAN JOAQUIN COUNTY <br /> • ,ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> C D A Cr-&Wg fqRl1 Page of <br /> Facility Address: City: Inspecti Da <br /> z o , i r M/ L r- s T� z 01 <br /> FA#: PR#: Program Element: <br /> B5a8 2 3 / <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 /> ank (2820) ❑ Containers (2821) #of Containers: TA#: Q hj <br /> (>250 gallons) (>55 gallons and X150 gallons) n <br /> 1 Product Type: /V•—/YJ <br /> Total Capacity: Q gallons <br /> (per tank or cumulativ or containers by product type) Install Date: <br /> ©wank(2820) ❑ Containers (2821) #of Containers: tTA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 / Product Type: <br /> Total Capacity: / '�'l G� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Ell7 <br /> Tank(2820) Containers (2821) #of Containers: 1� TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: /l P 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<50 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: 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: -z/,/ gallonsTotal Capacity for Site: Z�� (� gallons <br /> Comments: <br /> EHD Inspector: _ Reviewed 1 Date: Entered Da[e <br /> By Initial: 1 r,,.�l evlp,' Ey Initial: <br /> EHD 28-01 v V <br /> 01/16/08 <br />