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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-302y <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 /> Page-'/ of <br /> Facility Address: City: In ect'on e: <br /> -310S S ' e& �T4 2611 <br /> FA#: PR#: Program Element: <br /> C7 O� I 'PRO �Z 7 Z-- :F 1 Z <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#: <br /> (>250 gallons) (>55 gallons and<250 gallons) , <br /> 1 Product Type: Po P°v/j <br /> Total Capacity: 6 U O gallons <br /> (per tank or cumulative for-containers by product type) Install Date: <br /> ank(2820) WCntainers (2821) #of Containers: TA#: 05-/&D ! 7 <br /> >250 gallons) (>55 gallons and X250 gallons) <br /> 2 /2 O Product Type: -�_� C,IS e <br /> Total Capacity: �� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> C/Tank (2820) ❑ Containers (2821) #of Containers: TA#: Q-,5-.20 j q <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: _./li1 d t-0 r 0 � � <br /> Total Capacity: 2 O 0 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 /> 4 Product Type: /lit o t-0 r- O <br /> Total Capacity: 20 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 19 Containers (2821) #of Containers: TAM ?! .2j9j q� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: �)•t?S P.( C z�i 5 a aj.(017 df� <br /> Total Capacity: I (_.Q(;�5 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: /O�,(,a SG gallons Total Capacity for Site: f,B-f3-=� lU� 7q� gallons <br /> Comments: <br /> #2 <br /> ,Ta r 6 �lfeG� <br /> EHD Inspector: Reviewed D te: Entered Date: <br /> By Initial: .L By Initial: At �r <br /> EHD 28-01 <br /> 01/16/08 <br />