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SAN JOAQUIN COUNTY r r t <br /> f�NVIRONMENTALHEALTH DEPARTMENT <br /> T"r"~ ' `` 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 L 1 � J X A I L r!� �A j )-! Page 1 Of <br /> ��VVrr [� ,S' <br /> Facility Address: Ci Inspection D te: <br /> 1 Z >S o2, . t A7 "i e . <br /> -PR#: Progratt,;„El�ge}t, <br />� FA#: ZZ ��QQ(( LIQ UU <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> - <br /> ' r <br /> f ank (2820) ❑ Containers (2821) #of Containers: / TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) /� <br /> 1 Product Type: _Dx"A ? <br /> Total Capacity: . S-c.?O gallons <br /> (per tank or cumulative for containers by product type) Install Date:, <br /> f <br /> El Tank (2820) 19/Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) r <br /> 2 Product Type: a� <br />} Total Capacity: _ 1- 2- 0 gallons <br /> (per tank or cumulative for containers byproduct type) Install Date' <br /> k <br /> ❑ Tank(2820) Containers (282 1) #of Containers: TA# <br /> (>250 gallons)- (>55 gallons and<250 gallons) r` <br /> 3 Product Type: <br /> Total Capacity: _ .� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containeis(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> I` 4 Product Type: <br /> Total Capacity: 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<250 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: J gallons Total Capacity for Site: 7� gallons <br /> Comments: /'9 <br /> - - -- 3 Za 6-AflOAI <br /> EHD Inspector: Reviewed Date: / Entered Date: <br /> y f By Initial; l��. By Initial: <br /> f <br /> t EHD 28-01 <br /> 01/16/08 <br />