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SAN JOAQUIN COUNTY <br /> 9NVIRONMENTAL HEALTH DEPARTMENT <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 /> bZ Page --L of <br /> Facility Address: � 0� � Y City: � Inspection Dale: <br /> T ('(6n l e ( log <br /> FA#: Ll 8 <br /> Program Elemt: <br /> Tank/Container Information Z <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 /> Te 95)07 <br /> 5/ <br /> X Tank(2820) ❑ Containers (2821) #of Containers: TA#: Ala <br /> 1 Product Type: 1C. <br /> Total Capacity: Q 0 gallons <br /> (per tank or cumulative for Jontairimuct type) Install Date: <br /> r-4 <br /> 1A Tank(2820) ❑ Containers (282 1) #of Containers: TA#: eb�< <br /> 2 Total Capacity: V D gallons Product Type: _r6K ko - �� i �`! ✓rte <br /> (per tank or cumulative for 6ontainers by product type) Install Date: <br /> 95/ <br /> f Tank(2820) ❑ Containers (2821) #of Containers: A#: J" <br /> 3 Product Type: -Anu. /( ,44 <br /> Total Capacity: d l30 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> g Tank(2820) ❑ Containers (2821) #of Containers: TA#: -,P-El?'t45- <br /> 4 Total Capacity:42(1(45- 5 gallons Product Type: -rAntC 14/Z- - Tr AAS th7k <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: 196) 7� <br /> 5 Total Capacity: l49 ' 2�gallons Product Type:rAn1C 413 - QeCyy" (Ao (yv- <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: J D I r gallons Total Capacity for Site: 3 D ' �`.j S, S gallons <br /> Comments: <br /> EHD Inspector: Reviewed VA Date: Entered Date <br /> By initial: lfl,lo-o'6 By Initial: (w '1z <br /> *Abovekround 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 28-01 <br /> 01/16/08 <br />