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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN' <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 />11 <br />EHD 28-01 <br />01/16/08 <br />Fa. cility Name: <br />S�A M) n frL ofet <br />jq4.P(, <br />Page of <br />Facility Address: <br />N Q� <br />City: <br />�ka&V'l ./ <br />lnspe ion Date <br />u 6� <br />FA #: 6 <br />PR #: <br />d S 2' � � <br />Program Eleme5 <br />Tank/Container <br />Information <br />Complete for all sites with 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) ❑ Containers (2821) <br />#of Containers: TA#:��� $'Q <br />l <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: V 3 gallons <br />(per tank or cumulative for conta ers by product type) <br />Install Date: <br />)4 Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />2 <br />(>250 gallons) (>55 gallons and,<250 gallons) <br />L 4 s s-, -A t 4' <br />Total Capacity: Z ( � gallons <br />Product Type: e�e, <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />R Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />3 <br />(>250 gallons) C yg (>5 gallons and <250 gallons) <br />gZt <br />Product Type: <br />Total Capacity: 45992 M "�> gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 6545H3 <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: d (0 P3 'jallons <br />(per tank or cumulative fo containers product type) <br />Install Date: <br />B <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#:� <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />, <br />Product Type: &, �2 &ILI <br />1 3� <br />Total Capacity:(S 3 gallons <br />Install Date: <br />(per tank or cumulative o contain by ro ct type) <br />Total Capacity this Page: 0 (b gallons <br />I Total Capacity for Site: S / Z Zgallons <br />Comments: <br />EHTector: <br />L� <br />Reviewed <br />By Initial: <br />Date: <br />�(b <br />Entered Date: <br />By Initial: .7 <br />EHD 28-01 <br />01/16/08 <br />