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_ q SAN JOAQUIN COUNTY - <br /> �` "ENVIRONMENTAL;HEALTH DEPARTMEN 5 <br /> X-00 East Main Street, Stockton,CA 95202-3011-11 <br /> Telephone:(209)468-3420 Fax:,(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROU D PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Nam • sSTlJ� rO 1,D- 7 <br /> G Ln � Page of <br /> FacIllnAddr0. IVA V / n� City. Tl� {nspectioD3; } y <br /> .. FA#: �� � PR ts: �,� � ProgramZ RO / 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 /> gr"Tank(2820) ❑ Containers (2821) #oIf Containers: TA#: &6-17,3 t <br /> (>250 gallons) (�-55 gallons and<250 gallons) 1 <br /> 1 Product Type: S �h <br /> Total Capacity: �0 4 agallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) El Containers (2821) #o`f Containers:. TA#: &,5-/ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: �-o -a gallons <br /> (per tattle or cumulative for containers by product type) Iristall Date: <br /> \Totalpacity: <br /> 820) Contain (2821) #of Noainers: l TA#: <br /> (>55 gallons and Q5 lions)3 Product T e:,� .. � gall sInstall Date: <br /> mulative for containers by product type) <br /> ❑ Tank(2820) M Containers (2821) #}of Containers: 7 TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: /'Li ro <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 /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for-containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> f <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial, C Aon By Initial: g I <br /> HHD 28-01 <br /> 01/16/08 <br />