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rA <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME, <br />d00 East Main Street, Stockton, CA 95202-3029 <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 />0 W 1J <br />S'A IV /V C� <br />Page of <br />Facility Address: <br />City: <br />Inspection` Date: <br />-z-/o y <br />D © lit/ . <br />0 SS PA 6)"Ar V <br />4'f T 0 P <br />FA #:I <br />AC70 O 1 4``�` <br />PR #: <br />oS�.s"7�3 <br />Program Element: <br />28�� <br />Tank/Container Information <br />Complete for all sites with <br />cumulative aboveground storage of petroleum >_ 1320 gallons in tanks and containers over 55 gallons. <br />Complete one box for each tank or each cumulative container product type. <br />❑ Tank (2820) <br />Containers (2821) <br />#of Containers: TA#: S //Z,2 33 <br />1 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />_� <br />Product Type: <br />Total Capacity: <br />10 U gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />1;1,4ank (2820) <br />❑ Containers (2821) <br />#of Containers: TA#: 4, A3' j <br />2 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: <br />6/ o a o gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />1�1,/Tank (2820) <br />❑ Containers (2821) <br />#of Containers: TAM 0,36— <br />3 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: �"'4S <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Q Tank (2820) <br />❑ Containers (2821) <br />#of Containers: TAM jp d,3Le <br />4 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type' D_ci <br />Total Capacity: <br />d d o gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Of/Tank (2820) <br />❑ Containers (2821) <br />#of Containers: TAM Z5-iQ Q, 3 <br />5 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: <br />V-�� <br />�p6 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: <br />ZO gallons <br />Total Capacity for Site: gallons <br />Comments: <br />(j� 60 a <br />EHD Inspector: <br />. , <br />Reviewed <br />By Initial: <br />ate: �-/ <br />/`1 x <br />Entered Date: <br />By Initial: �LyD� <br />EHD 28-01 <br />01/16/08 <br />