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SAN JOAQUIN COUNTY <br /> "NVIRONMENTAL HEALTH DEPARTMENT <br /> `sd East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web.www.sjgov.org/ehd <br /> ABOVEGROUND rrPETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> !7 c- Page of <br /> Facility Address: City: Inspection D e: <br /> FA#: PR#: Program Element: <br /> e aL0,4122rc2az o2a� 3l <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: TAW: /g�/(�2 <br /> (>250 gallons) (>55 Ions and<25 gallons) <br /> 1 Product Type: _ <br /> Total Capacity: ✓ gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> C'Tank(2820) ❑ Contain 2821) #of Containers: TA#: Q�J�Pigg <br /> (>250 gallons) (>55 gallons and Q50 lions) �- <br /> 2 Product Type: 1444 <br /> Total Capacity: g L110 <br /> (per tank or cumulative for containers by product type) Install Date: _ <br /> ❑ Tank(2820) ❑ Containers(282 1) f Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Pr ct Type: <br /> Total Capacity: gallons Install te: <br /> (per tank or cumulative for containers by product type) — -- <br /> ❑ Tank(2820) ❑ Containers (282 1) #of Contain TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or emulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: #: <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: b vallonsj Total Capacity for Site: gallons <br /> Comments: <br /> �J <br /> � 6 <br /> EHD Inspector: Reviewed Date: Entered / Date: <br /> By Initial: By Initial: C,Z `y B <br /> EHD2MI <br /> 01/16/08 <br />