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SAN JOAQUIN COUNTY <br /> 'ENVIRONMENTAL HEALTH DEPARTMENry <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 /> KaE DN 7RUCK10(r- Page of <br /> Facility Address: City: Inspecti Date <br /> _ M�zr� cADRa s7 r 18 � $ <br /> FA#: PR#:q Program�IeIQ <br /> %JoZ�J C VU <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 /> gr'Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) _ v/f <br /> 1 Product Type: <br /> Total Capacity: 3&e> gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: fA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per teak or cumulative for containers by product type) —— <br /> ❑ Tank (2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 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: TAM <br /> (>250 gallons) (>55 gallons and Q50 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 Q50 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: 3 ('!fl gallons I Total Capacity for Site: 3 d 8 gallons <br /> Comments: <br /> 0 Al <br /> EHD brspcctor: Reviewed Date: ,I Entered Date: <br /> r ° By Initial: ,,lq.0b By Initial: <br /> "1 v B <br /> EHD 2"1 <br /> 01/16108 <br />