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- SAN JOAQUIN COUNTY <br /> �.ENVIRONJENTAL HEALTH DEPARTMENP <br /> 600 East Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: I <br /> Page Tof <br /> Facility Address: City: Inspection Date: <br /> 3 1�06LG -on d <br /> FAFR S 2 7 I � 8 Program Elemj>t: <br /> Tank/Container Information 2 <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> r,91 <br /> Tank(2820) El Containers Containers: TA#:Containers (2821) _A16,46 <br /> &WJ'"t_ <br /> 1 Total Capacity: —Io Bga011ons Product Type:I"V_ <br /> (per tank or cumulative for ontaproduct type) Install Date: I� gg <br /> Ti9o � <br /> Tank(2820) ❑ Containers (2821) i`tof Containers: If <br /> moi, G,a�nt.lze <br /> 2 'I'q/2 Product Type: -rAn1C If to Q��i <br /> Total Capacity: gallons -- <br /> (per tank or emulative for ntainers by product type) Install Date: I q q 5 <br /> 8677 <br /> Tank (2820) ❑ Containers(2821) #of Containers: A#: � <br /> 3 (O>n tO Product Type: -rA�� d�/ I — Q p�i �i� <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2882�21) #of Containers: TA#: A!SI?`?j'S J <br /> 4 (%J allons 2 Product Type: -rAAit !'�/'Z — Tf AAS <br /> Total Capacity g <br /> (per tank or cumulative for containers by product type) Install Date: L._I <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: '95) 7� 5 <br /> 5 YKI Total Capacity: lam—gallon3 Product Type:rtAnl� �}13 — Q¢CDuar� 6All <br /> Sorle�� <br /> (per tank or cumulative for containers by product type) Install Date: I q AFD ops <br /> Total Capacity this Page: —p �—r� — gallons Total Capacity for Site: � t' gallons <br /> Comments: 10 5 y of 3 g GrGI 7, <br /> P� lam r <br /> Oyt <br /> CU1 to <br /> EHD Inspect Reviewed Date: Entered Date: <br /> 1z&4 IBy Initial: 1�,1(}Q� By Initial: m <br /> *Abov ound storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> **Container means a storage device designed to be moved when full. <br /> EHD 2M 1 <br /> 01/16/08 <br />