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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN" <br />,)00 East Main Street, Stockton, CA 95202-30�-, <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Weh: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name: <br />W) <br />G <br />Page L of <br />' <br />Facility Address: <br />City: <br />Inspecti n <br />3 of d <br />1/7- AL <br />FA #: <br />"00/ a <br />I PR #: <br />05;7- g0LQ.2- <br />ProgramElement: <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 />Complete one box for each tank or each cumulative container product type. <br />A47ank (2820) <br />❑ Containers (2821) <br />#of Containers: TA#: Qf /& � $ 7 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />1 <br />2 a or k) <br />Product Type: ,,Qzza�. <br />Total Capacity: <br />gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />;4ank (2820) <br />❑ Containers (2821) <br />#of Containers: - TA#:�{-�`� <br />2 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: �,� <br />Q <br />Total Capacity: <br />l O 4 d gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) <br />❑ Containers (2821) <br />#of Containers: TA#: <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />3 <br />Product Type: <br />Total Capacity: <br />gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) <br />❑ Containers (2821) <br />#of Containers: TA#: <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />4 <br />Product Type: <br />Total Capacity: <br />gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) <br />❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: <br />gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: <br />3 <br />gallons <br />Total Capacity for Site: 3 Q O gallons <br />Comments: <br />Z& <br />2 <br />EHD Inspector: /� <br />� <br />Reviewed Date: t( <br />By Initial �. Vr 1) v <br />Entered Date: <br />By Initial: ry <br />t <br />EHD 28-0t <br />01/16/08 <br />