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SAN JOAQUIN COUNTY - - <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> I600 East Main Street, Stockton,CA 95202-3029 <br /> I Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> I ABOVEGROUND:PETROLEUM-STORAGE PROGRAM SURVEY FORM' <br /> Facility Name- Page of <br /> Ui�1 Z- � T 9A� e <br /> t Facility Address: G Inspection <br /> 1 Z �- o - rS tq 2 t,11W L014 6 jo <br /> FA#: PR#: V Progra I e <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 e: <br /> til(2820) ❑ Containers(282 1) Hof Containers: ' / TA#: <br /> (>250 gallons) (>55 gallons and X250 gallons) n 1 <br /> 1 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date' <br /> ❑ Tank(2820) Containers (2821) Hof Containers: TA#:. <br /> (>250 gallons) (>55 gallons and 450 gallons) . <br /> 2 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 450 gallons) / s f� <br /> 3 Product Type: <br /> Total Capacity: .� gallons <br /> 1 (per tank or cumulative for containers by product type) Install Date' <br /> s <br /> Tank(2820) ❑ Containers(2821) Hof Caritainers: ' TA#: <br /> (>250 gallons) (>55 gallons and 450 gallons) <br /> 4 Product Type: �]�f r—Ne 7 <br /> Total Capacity: 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 450 gallons) <br /> 5 ,Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date' <br /> l <br /> Total Capacity this Page: gallons Tota!Capacity for Site: 1 � gallons <br /> Comments: <br /> ` 13Z-0 6-A(10k <br /> t <br /> v�- I I&I Iry �l <br /> EHD Inspector: Reviewed Date: Entered I Date. <br /> By Initial: 1 •@ By Initial: <br /> ' EHD 2"1 <br /> {, 01/16/08 <br />