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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 /> l)� UG L ISD C-A T/ D a A" �. �NST e 7"v�i o nl Page of <br /> Facility Address: City: [nspecti n Dat <br /> 2 Soo j�CASS61J l� r� �/Ql9 fi <br /> FA#: PR#: Program EI ment: <br /> noo71 S8 p �g3v <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 Tete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) Containers (2821 <br /> ns and<250 gallons) <br /> 1 Product Type: ,. <br /> Total Capacity: 2-2-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> N-*'rank (2820) ❑ Containers (2821) #of Containers: , TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) e <br /> 2 Product Type: <br /> Total Capacity: O D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> .01 <br /> [P`f'ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: ,�..GP�� <br /> Total Capacity: z00e gallons 7j41'r?" <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 1:1 Tank (2820) K Containers (2821) #of Containers: TA#: eg'j`J 7/ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> <br /> <br /> <br /> <br /> Tank (2820) ❑ ContaiRers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: ,(/ <br /> Total Capacity: '/'mB gallons Install Date: <br /> <br /> gallons <br /> Comme„t- <br /> EHD Inspector: Reviewed , Date: Entered Date: <br /> ! By Initial: C��\1 D� Ej �� By Initial G1 <br /> EHD 28-01 <br /> 01/t6/08 <br />