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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 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: ^L <br /> /� � � r-.�N O / � S /� A�-!+✓� Page 2"_of <br /> Facilitv Address: City: Inspectio Da <br /> Al, lWv yl 1 <br /> tv <br /> FA#: PR#: Program Eleme t: <br /> z s -�, g3 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 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) ❑ Containers (2821) #of Containers: TA#: p6-j7,aZ t <br /> (>250 gallons) (>55 gallons and<250 gallons) � <br /> 1 Product Type: ,. R5 <br /> Total Capacity:'Z 0 p o 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: �17 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: 0j-e/;IyP <br /> Total Capacity: Z p 0 g2_0_gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> U,- ank(2820) ❑ Containers (2821) #of Containers: TA#: 12(6'1 "24 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: 2 o D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 'Tank(2820) ❑ Containers (2821) #of Containers: TA#: 196Q!7, Q2 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: -Z-610 O gallons. <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Prfank(2820) ❑ Containers (2821) #of Containers: #: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: Z 0 0 0 ' gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: I O U 0 gallons FTotaI Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date <br /> C! , By Initial: By Initial: O <br /> EHD 28-01 <br /> 01/16/08 <br /> r <br />