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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL 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: I' I <br /> Qku�j �/� �'e S Page ( of <br /> Facility Adess: Inspection Da te: <br /> 41� <br /> � D �iw <br /> FA#: PR#: O S 8 Program Element: <br /> 00032 L �� 29T-Z <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 type. <br /> ❑ Tank(2820) X Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: 1 G d*A-t>Al& d; <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 5(00 0� o5��ebD <br /> Tank(2820) El Containers (2821) #of C('�i ii4ers: TA#: Ob��� ! •l� <br /> (>250 gallons) (>55 gallons and<250 g 110 s)2 Product Type: 1)1-0 •{ <br /> Total Capacity: -- _ga lons � <br /> <br /> ❑ Tank(2820) XContainers (2821) #of Containers TA#: LP <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3W—14 0 5�5�f*n ar,�T <br /> Product Type: Di r So 5t�-f�td <br /> Total Capacity: gallons ( <br /> (per tank or cumulative for containers by product type) Install Date: <br /> X- l� <br /> Tank (2820) Containers (2821) #of Containers: TA#: 6-ZZeei�'3 <br /> (>250 gallons) (>55 gallons and<250 gallons) I <br /> 4 /1 Product Type: U') <br /> Total Capacity: gallons <br /> <br /> <br /> Tank (2820) ❑ Containers (2821) #of Containers: 1 TA#: <br /> '3 Al <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: 2-50 gallons Install Date: ° <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: �5 gallons Total Capacity for Site: gallons <br /> Comments: <br /> rIns W?-1 Reviewed Date: Entered DateI'gel"q A �WBy Initial: By Initial: `` <br /> 12113 k-e /2� r10 <br /> EHD 28-01 <br /> 01/16/08 <br />