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SAN.IOAQUIN COUNTY <br /> ✓ <br /> ENVIRONMENTAL HEALTH DEPARTME' <br /> 600 East Main Street,Stockt6n,CA 95202-309 <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 />' r Pa C <br /> Ll� a U 1 G A TI ow S, Iv Page of <br />` Facility Address: City: Inspectio Date <br /> Zo076 <br /> FA#: <br /> am <br /> Progra Element: <br /> o � l 3 Z 47 g3 <br /> Tank/Container Inforthation <br /> Complete for all sites with cumulative aboveground storage of petroleum Z 1320gallons in'tanks and containers over 55 gallons. <br /> Com lete one box for each tank or each cumulative container roduct type:' <br /> Tank(2820) ❑ Containers (2821) �#of Containers: .- TA#: <br /> (>250 gallons) (�55 gallons and<250 gallons) <br /> 1 Product Type;, <br /> Total Capacity: d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> } <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (555 gallons and<250 gallons) <br /> 2 _ -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: <br /> (>250 gallons) (>55 gallons and<50 gallons). <br /> 3 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 /> 4 Product Type: <br /> Total C9pacity: . , gallonsI <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 Install Date: <br /> (per tank or cumulative for containers byproduct type) <br /> Total Capacity this Page: gallons Total Capacity foe Site: gallons <br /> Comments: <br /> r - <br /> 3 7�J <br /> EHD Inspector: 7 Reviewed Date: ' Entered Date: <br /> By Initial: By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />