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t _ <br /> _ SAN JOAQUIN COUNTY <br /> iENVIRONMENTAL HEALTH DEPARTMENI� <br /> 600 East Main Street, Stockton,CA 95202-302 <br /> Telephoner(209)468-3420 Fac.(209)468-3433 Web.www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: ♦ i <br /> CTI.O-W t/ tj� Page / of j <br /> Facility Address: Cap: V Inspect' n D e: <br /> FA#: PR#: Program Element: <br /> F f no s,0 o� S 4,D <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 />' <br /> Complete one box for each tank or each cumulative container roduct e. <br /> Tank(2820) ❑ Containers (2821) #of Containers: -_TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 i Product Type: <br /> Total Capacity: 14 Q O gallons <br />+ (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 2150ntainers (282 1) #of Containers: .3 TA#: s <br /> (>250 gallons) (>55 gallons and<250 gallons) !� <br /> 2 Product Type: ky f %v` <br /> Total Capacity: gallons . <br /> (per tank or cumulative for containers by product type) Install Date' <br /> ❑ Tank(2820) . ILXContai.ners (282 1) . #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: a / (L,., <br /> Total Capacity: �. gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (282 1)" .#of Containcrs: 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 byproduct type) Install Date: <br /> i <br /> Total Capacity this Page: Z gall onsTotal Capacity for Site: Z S gallons <br /> l Comments: ' s •e. t ` ` <br /> L <br />{ EHD inspector: /,� Reviewed Date: Entered Date: <br /> C1 r By Initial: VA <br /> �.ZQ(l� By Initial: 1 <br /> E EHD 28-01 l <br /> 01/16108 <br />