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SAN JOAQUIN COUNTY <br /> sENVIRONMENTAL HEALTH DEPARTMENT <br /> `4%%East Main Street,Stockton,CA 95202-302 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> C 14 ASE Q46 T Page of <br /> Facility Address: / City: T-0 Inspection Qaje.a IO <br /> FA#: PR#; Program (le53� <br /> 0 o z -a p <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 /> Com ete one box for each tank or each cumulative container product <br /> ❑ (2820) ontainers (2821) #of Containers: TA#: D�-142$ `7 4 <br /> (>250 ons) (>55 gallons and<250 gallons) / <br /> I Product Type: D/ L <br /> Total Caper 'ty: !S d gallons Install Date: <br /> (per teak or cum. 've for containers by product type) <br /> ❑ Tank(2820) Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>5 Ilons and<250 gallons) <br /> 2 Product Type: 06 TF <br /> Total Capacity: "- d gallons Install Date: <br /> (per tank or cumulative for containers by uet type) <br /> ❑ Tank (2820) l3Containers (2 1) #of Containers: 3 TA#: � ,3-7 <br /> (>250 gallons) (>55 gallons and Q50 gall <br /> 3Product Type: 0,/ L <br /> Total Capacity: —'5b gallons stall Date: <br /> (per tank or cumulative for containers by product type) <br /> Tank(2820) ❑ Containers (2821) #of Co iners: TA#: 5 g <br /> (>250 gallons) (>55 gallons and¢50 gallons) <br /> 4 Product T .S �E <br /> Total Capacity: Oa 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 a� Product Type: <br /> Total Capacity: �� a gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Z 9 gallons Total Capacity for Site: Z gallons <br /> Comments: <br /> � o <br /> EHD Inspector: Reviewed � 1 Dale: l Entered Date: <br /> 9y initial: �1r1N -'yI.J'6 By Initial: <br /> EHD2"t <br /> 01/16/08 <br />