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SAN JOAQUIN COUNTY <br />.NVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-302y <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orglehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Nam <br />Y <br />G/` <br />L -AS j�� <br />Page of <br />Facility Address: <br />City: <br />Inspection ate: <br />FA #: <br />oo/o'6z? <br />PR #: <br />�zU <br />Progra Element: <br />�- 3v <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br />Complete one box for each tank or each cumulative container product <br />type. <br />0-1 ank (2820) <br />❑ Containers (2821) <br />#of Containers: TAM (Q <br />1 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: <br />.S O O gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) <br />OFC`ontainers (2821) <br />#of Containers: TA#: <br />2 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />. <br />Product Type: <br />Total Capacity: <br />5 S gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Tank (2820) <br />❑ Containers (2821) <br />#: <br />#of Containers: TAO <br />3 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: �fI <br />Total Capacity: <br />o v a a <br />gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />an/ <br />C�'ank (2820) <br />❑ Containers (2821) <br />#of Containers: TA#:a— <br />4 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />- <br />Product Type: <br />-n <br />Total Capacity: <br />/U U 0 O gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) <br />❑ Containers (282 1) <br />#of Containers: TA#: <br />(>250 gallons) <br />5 <br />(>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: <br />gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity ' ' Z p s' j'�' <br />gallons Total Capacity for Site: Z D SSS gallons <br />Comments: <br />EHD Inspector: /b <br />(� <br />Reviewed Date: <br />By Initial: v� 04 <br />Entered Date: <br />By Initial: Q <br />EHD 28-01 <br />01/16/08 <br />