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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN' <br />600 East Main Street, Stockton, CA 95202-3025 <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 />Page of <br />Facility Address: <br />City: <br />xV6 <br />Z <br />InspectiD te: <br />1 oT <br />2-2 o <br />M A Al <br />14 <br />s <br />FA #: <br />O GO <br />PR .� � � <br />a <br />Prog m Element: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground <br />storage of petroleum > 1320 gallons in tanks and containers over 55 gallons. <br />Complete one box for each <br />tank or each cumulative container product type. <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: Q�/(Q «p(,g <br />(>250 gallons) (>55 gallons and <250 gallons) <br />1 <br />Product Type: <br />Total Capacity: Z_ C7 O U gallons <br />(per tank or cumulative for containers by product type) <br />Install Date- <br />ate: <br />"a <br />a (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: D5( to I& <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />1214 <br />Total Capacity: _� ?, a O O gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Q,1 ank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#• p!j I i�e $ <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: '0Z_ Od O gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />P Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: r9,5j it I [Q Q <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />(j <br />Total Capacity: / D O d gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Lank (2820) ElContainers (2821) <br />#of Containers: <br />TA#: <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />jj�/,�f?� 0-/ <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: % (-U <br />gallons <br />Total Capacity for Site: v gallons <br />Comments: <br />EHD Inspector <br />/ 7 <br />Reviewed Date <br />By Initial: <br />Entered Date: <br />By Initial: <br />�qj <br />EHD 28-01 <br />01/16/08 <br />