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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 />Facility Name: <br />I - <br />Fm iN C <br />Page 2 of <br />2 <br />Wee✓ YS <br />Facility Address: �,. L <br />- -3Ar '+�9'C��C�MP. <br />City: /' <br />� <br />Inspection Date: <br />a <br />FA #: <br />PR #: <br />1 <br />Program Element: <br />2632 <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage <br />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 />Chi Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: Asow4c of ( <br />wfl <br />Total Capacity: 1 gallons <br />(per tank or cumulative for containers by product type) <br />Install Date:OI <br />I 1 <br />® Tank (2820) ❑ Containers (282 1) <br />#of Containers: TA#: B <br />$ <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: iC O <br />� <br />II N 1� <br />Total Capacity: 36, Pik gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />P Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />(>250 gallons) (>55 gallons and <250 gallons) <br />�- <br />3 <br />' <br />Product Type: d t'eK <br />Total Capacity: 01X10 gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />X Tank (2820) ❑ Containers (282 1) <br />#of Containers: TA#: �( <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: Vrefe I <br />Total Capacity: aP gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />(>250 gallons) (>55 gallons and <250 gallons) <br />5 <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: 2 <br />gallons <br />Total Capacity for Site- $' <br />!� gallons <br />Comments: <br />EHD Inspector: <br />Aw� <br />Reviewed {� Date: <br />By Initial: 3 15 <br />Entered <br />By Initial: <br />Date: <br />6,51 <br />6 <br />( L <br />EHD 28-01 <br />01/16/08 <br />