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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN' <br /> 600 East Main Street, Stockton,CA 95202-30.- <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Weh:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: - Pae of _Y <br /> i% S i r 1�M o i l S �� A 1 '✓GJ g <br /> Facility Address: 2 /v City: Inspectioq Dave: <br /> FA#: PR#: Program Eleme t: <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: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) U,1 <br /> 1 Product Type: <br /> Total Capacity: 2 d O or Q 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) ✓ C <br /> 2 Product Type: <br /> Total Capacity: Z p Q 4'Z) gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> VT'ank(2820) ❑ Containers (2821) #of Containers: TA#: '?2 i:�j? <br /> (>250 gallons) (>55 gallons and<250 gallons) {+�, _. �/ <br /> 3 Product Type: <br /> Total Capacity: '�o d&0 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 /> 4 Product Type: <br /> Total Capacity: z-00 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 2' ank(2820) ❑ Containers (2821) #of Containers: #: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: Z V 0 0 4 } gallons <br /> (per tank or cumulative for containers by product type Install Date: <br /> Total Capacity this Page: 0 gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> p C 1 By Initial: 2U Z 6 By Initial O <br /> EHD 28-01 <br /> 01/16/08 <br /> 1 <br />