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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN'" <br />{ y a 600 East Main Street, Stockton,CA'95202-30 <br /> fi <br /> Telephone:(209)468-3420 Firs:(209)468-3433 Web:www.sjgov.org/ehd <br /># ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> LA f O kof C I 1 or- (3vv SimT-erZ-, :v )q�1 Page "1 of <br /> Facility Address: City: F /' Inspection Date: <br /> FA#: PR#: " � - Prot m Element: <br /> 19 Rae? Dia OV <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 /> Com letc one box for each tank or each cumulative container product type. <br /> Er"Tank (2820) ❑ Containers (2821) #of Containers: TA,#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product.Type: <br />!. Total Capacity: gallons <br /> l' (per tank or cumulative for containers by product type) Install Date: <br /> E Tank(2820) 1 ElContainers (2821)Q #of Containers: TAM <br /> r (>250 gallons) (>55 gallons and 50 gallons). <br /> " Product'Type: �(_p <br /> �� <br /> Total Capacity: ,� a d gallons <br /> k (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons. . <br /> (per tank or cumulative for containers byproduct type) Install Date' <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 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: gallonsTotal Capacity for Site: �'C--, gallons <br /> Comments: <br /> EHD Inspector: Re viewed Date: Entered Date: <br /> By Initial- By Initial: ! <br /> EHD 28-01 [ <br /> 01/16/08 <br />