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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTNIP <br /> X00 East Main Street, Stockton,CA 95202-3,_. <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 /> O IJ Page of <br /> C(Z l <br /> Facility Address: City: Inspectio Dat <br /> q- 00 S. L„'Jc. oc rl r o� <br /> FA#: PR#: Progra EI m <br /> oolc) 05 S2ZCos - <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum Z 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) #of Containers: TA#: 19-6/(27517 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: r <br /> fizalatz— <br /> Total Capacity: 0,1 D a D gallons <br /> (per tank or cumulative for coiftainers by product type) Install Date: <br /> 0 Tank(2820) L containers (2821) #of Containers: 'L. TA#: <br /> 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) O/ <br /> Product Type: <br /> Total Capacity: 4 a gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) W"60ntainers (282 1) #of Containers: TA • (P� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3Product Type: <br /> Total Capacity: Zi 2d 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 /> 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: 3-0� y� <br /> Total Capacity this Page: / 0 `] a gallons Total Capacity for Site: / a ? J v gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Dat]�Llll <br /> By Initial: (�� By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />