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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN'. <br />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 />�y <br />Facility NaG...Gm*4 <br />i cbm , <br />Page of <br />Facility Ad dress:� j 1 <br />City: Qeoi <br />`/" <br />Inspection Date: <br />FA #: � � <br />PR #: <br />Program Element: <br />Tank/Container <br />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 type. <br />❑ Tank (2820) Containers (2821) <br />#of Containers: f TA#:C% Z� l $Z7 <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />" <br />/go <br />Product Type: V�W <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) Containers (2821) <br />#of Containers: TA#: <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Total F 9 <br />Product Type: Gam►' <br />Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />V Tank (2820) El Containers (2821) <br />#of Containers: TA#: <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: M gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />[� Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />y <br />Product Type: v <br />Total Capacity: ^ gallons <br />Install Date: <br />(per tank or cumulative for cont iners by product type) <br />Tank (2820) El Containers (2821) <br />#of Containers: 1 TA#: ��rj'1, <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: b� I <br />Total Capacity: ", M gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />r <br />Total Capaci this P ga ns <br />Total Capacity for Site: g lb gallons <br />Comments: ' -7-11 <br />;'r— 651 <br />IA1 rX <br />'siol'i l�, <br />c�� a� °� o� ►�t,� <br />EHD Insp <br />%n <br />Reviewed <br />By Initial: <br />I <br />Date (/ <br />Entered Date: <br />By Initial: <br />j1X1,191 <br />EHD 28-01 Lf <br />01/16/08 <br />