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SAN JOAQUIN COUNTY <br /> "rWIRONMENTAL HEALTH DEPARTMEN'1'—i <br /> o00 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 N me: <br /> .Sy/V Y v A � -7' C v L, L D Page of !� <br /> Facility Address: City: Inspection te: I <br /> - E v e 1VT C- ' . C' 4 i3 <br /> FA#: I r PR#: Program lent: <br /> �� me <br /> Tank/Container Information <br /> Comple 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#: D5-/-1142W <br /> 1 <br /> (>250 gallons) (>55 gallons and<250 gallons) Type: <br /> Product T e• <br /> Total Capacity: 150 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> tl/Tank(2820) ❑ Containers (2821) ##of Containers: TAM 1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: S gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ontai 821) #of Containers: TAM 695-1.7 <br /> (>250 gallons) (> al ns an <250 gallons) <br /> 3 Product Type: 14'r-' O� <br /> Total Capacit gallons <br /> (per tank or cumin 've for containers product type) Install Date: <br /> E7r <br /> ❑ Tank(2820) rgaflons <br /> (2821) #of Containers: l TAM 195-1 7 <br /> (>250 gallons) 50 gallons) ,74 Product Type: �l.r LiTotal Capacity: gallonsAlf&I LUUU(per tank or cumulative ct type) Install Date: <br /> [H'Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) TIC <br /> 0 <br /> 5 Product Type: (i!/•� S r <br /> Total Capacity: Z -0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: J" gallons Total Capacity for Site: gallons <br /> Comments: <br /> /f/A 7 �i <br /> 1 1061111 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: ` By Initial: <br /> EHD 28-01 (zu I <br /> 01/16/08 <br />