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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTMEl <br /> 600 East Main Street,Stockton,CA 95202-30 <br /> • Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orgtehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: C / <br /> Lv 6 h Page of <br /> Facility Address: City: Inspc ti a Da[ <br /> ,yq ✓g ��- LN 57c 3 B� <br /> FA#: PR#:� Prag Element: <br /> OiVr 33 II <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: TA#: _d5//r y 'Z <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: �/A 6/ � <br /> Total Capacity: /p l70 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 /> 2 Product Type: f <br /> Total Capacity: 23 0 gallons <br /> (per tank or cumulative for coma' ers by product type) Install Date: <br /> ❑ Tank(2820) Containers (282 1) #of Containers: TA#: /(meq <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 3 Product Type: 0/ L t <br /> Total Capacity: �3 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank(2820) al/ <br /> Containers (2821) #of Containers: TA#: t75/ D <br /> (>250 gallons) (>55 gallons and Q50 gallons) Type: <br /> N ^a <br /> 4 Product T e: 'r/f-/f <br /> Total Capacity: b gallons <br /> (per tank or cumulative for continers by product type) Install Date: <br /> El Tank (2820) IV/containers (2821) #of Containers: _� TAM aeu <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: l.1/F! n'j(z <br /> Total Capacity: ti cp-r) gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 0 gallons Total Capacity for Site: 777Vgallons <br /> Comments: <br /> a <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> G" By Initial: ` �l� �.tt,D¢ By Initial: <br /> EHD 28-01 <br /> 01/1&08 <br />