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SAN JOAQUIN COUNTY <br /> 'NVIRONMENTAL HEALTH DEPARTMEN' <br /> ,,,.000 East Main Street,Stockton,CA 95202-302?w <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: y�s,) / /C/ G Page 2– of <br /> C U m ,�I v C/ Inspection Date: / <br /> Facility Address//: j / n /�O C.✓/ P� <br /> FA#: PR tt:BElement: <br /> Elemen <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 /> Com ete one box for each tank or each cumulative container product <br /> ❑ Tank(2820) Containers (2821) W TA#: 1<< <br /> (>250 gallons) (>55 gallons and Q50 gallons <br /> 1 Product Type: /F /L <br /> Total Capacit : gallons Install Date: <br /> (per tank Wive for containers by product type) <br /> ❑ Tank(2820) ontainers (2821) #of Co TAM q 1` <br /> (>250 gallons) (>55 gallons and 250 gaLLons) �\ <br /> 2 Product Type: rL� Tom?/ 6 i U nn <br /> Total Capacity: gallons In <br /> Date: <br /> (per tank cumutitrve for containers by product type) <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 galions and<50 gallons) - <br /> 3 <br /> Total Capacity: O-� � Product Type:gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) Q Containers (2821) #of Containers: 2— TAM &u6-"o2dCo <br /> (>250 gaUcmd (>55 gallons and<250 gallons) <br /> 4 Product Type: . a/z8x$' <br /> Total Capacity: // 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 196-Z02.37 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 /�� Product Type: <br /> Total Capacity: gallons <br /> (per tank or emulative for containers by product t)pe) Install Date: <br /> Total Capacity this Page: �I ,/. j gallons Total Capacity for Site/:o�Q gallons <br /> Comments: � CT✓,e.�( f-/' / 2� � 77 —1 <br /> ll <br /> EHD Inspector: Reviewed Dat Entered Date: <br /> l� By l itial: U�' 9_�'I� By Initial: <br /> EHD 28-01 c� <br /> 01/16/08 <br />