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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEP ARTMEi <br /> 600 East Main Street, Stockton,CA 95202-30 <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 /> T1 F L1/ sF$ Page / of <br /> Facility Address: City: Inspection Da <br /> 11 3 a M A/A /vIR�o 7-7- a y <br /> FA#: PR#: Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 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#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1Product Type: <br /> Total Capacity: SO d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> (Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type:yio%D/L. Oi <br /> Total Capacity: Sb gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ItsntContainers (2821) #of Containers: TA#; 0,51/p'{(o0 <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 3 Product Type: t�-6,p2 01 V <br /> Total Capacity: /10 gallons <br /> (per tank or cumulative forcontainers by product type) Install Date: <br /> El Tank (2820) O Containers (2821) #of Containers: / TAM 06-/(e'U <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: !/rx/J <br /> Total Capacity: _�0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: /9i5/1py& <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: /S7 TF F jiv <br /> Total Capacity: 2 ZD gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: �j gallons <br /> Comments: <br /> EHD inspector: Reviewedvlo�I Date: Entered Date <br /> N : <br /> By Initial: �.�.0 By Initial: PY <br /> EHD 28-01 <br /> 01/16/08 <br />