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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 />Facility Name: <br />PU S�• K- TA1`n . �� <br />f a� �" t% <br />Page of <br />Facility Address: <br />City: <br />Inspect' n Date: <br />66 <br />FA #:Ct <br />PR #: <br />Program Element: <br />S <br />Tank/Container 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) ElContainers (2821) <br />#of Containers: <br />TA#: <br />1 <br />(12T5 gallons) (>55 gallons and <250 gallons) � <br />Total Capacity: Li F J ql . S 4/,Y5g )oduct Type: `) c, Q <br />S�� <br />gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: BLj j5_g94 <br />2 <br />1250 gallons) (>55 gallons and <250 gallons) <br />S�j 3 � 1Lf <br />Product Type: � G� <br />U (JI j <br />. <br />Total Capacity: <br />gatSons <br />Install Date: <br />(per tank or cumulative for containersoduct e) <br />'Tank(2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: f.ZS-1 q$ 07 <br />3 <br />>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: �� , <br />U Oy (g A']� (p q� J <br />Total Capacity: � jallons <br />Install Date: <br />(per tank or cumulative f coo iners by pro uc type) <br />[ Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: enT161,3s <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />3Z- ��' S <br />Product Type: �� , <br />0 IU j aA'IA <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulativ r containers by prod t type) <br />as <br />V Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: &_6'�iq <br />5 <br />(1250 gallons) (155 gallons and <250 gallons) <br />-)1 J � 2Z S <br />Product Type: �, <br />(j j.► l �� (9 � <br />Total Capacity: gallons <br />(per tank or cumulative containers by pr duct type) <br />77 12 <br />Install Date: <br />Total Capacity this Page: 01 g6LfI gallons <br />Total Capacity for Site: � 5'012 1 3 < 2 gallons <br />Comments: <br />EHD <br />Reviewed <br />Date: <br />Entered Date: 1 <br />mect <br />r�� <br />By Initial: <br />By Initial: <br />EHD 28-01 <br />01/16/08 <br />