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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENI <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 /> 6rp wG>�,f— �-- Page e-2— of <br /> Q <br /> Facility Address: City: Inspe tion Dat7og <br /> v u S � �� 2 o <br /> FAM PR#: Pro am Element: <br /> v vel <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 /> KTank(2820) ElContainers (2821) #of Containers: TA#: <br /> (IT5 gallons) (>55 gallons and<250 gallons) <br /> 1 d Product Type: <br /> Total Capacity: A32-gallons Install Date: <br /> (per tank or cumulative for contain by product type) <br /> Tank (2820) ❑ in (2821) of Containers: TAI s <br /> (>2 allons) 5 gallons and<250 gallons) <br /> 2 Pro Type: L <br /> Total Cap *ty: 2 allons Install Dat <br /> (per tank or cumula or containers by product <br /> 1�( Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) yp D�r n �� <br /> 3 Product T e: �G. C <br /> Total Capacity: 20i `- gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 <br /> (>250 gallons) (>55 gallons and<250 gallons) n � 4T <br /> Product Type: I`e� , IV <br /> Total Capacity: liN) gallons <br /> (per tank or cumulative for contain 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: (Jv�/'I CJ1'�'S � �d� i 41 Lk__' <br /> Total Capacity: 07i gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: I gallons Total Capacity for Site: C Q 2­0 gallons <br /> Comments: <br /> EHD Inspect Reviewed Date: Entered Date: <br /> �� 1 By Initial: By Initial:I&L 2 <br /> EHD 28-01 V" v <br /> 01/16/08 <br />