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SAN JOAQUIN COUNTY <br /> %woe ENVIRONMENTAL HEALTHDEPARTMENftd <br /> r. : 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web.www.sigov.org(chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: n /� Al / <br /> /✓ � V e 9 5s1 ri�Jn C 1903 T)e 11 C'T/e A .5'9 IQY Page of � <br /> Facility Address: City: Inspection D <br /> 6' 5 6S G T• F C id : c <br /> FA#: PR#: I Program EIe <br /> I 05a8 784e <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 /> Tank(2820) ❑ Containers (2821) #of Containers: T <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 500 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) 01(fontainers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: TWZit/il/£le. <br /> Total Capacity: gallons Mall Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> g Product Type: <br /> Total Capacity: gallons Mall Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: S S gallons Total Capacity for Site: 5511 gallons <br /> Comments: <br /> EHD Inspector. Reviewod Date: / Entered Date: <br /> By Initial: t s sy `�,'yt•Ot6 By Initial: <br /> 14 <br /> EHD 28-01 v� <br /> 01/16/08 <br />