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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 /> 6 F, V- 1 Q + �UI.J Ti.- C - Page S of <br /> Facility Address: City: lnspectlo Date: <br /> t"c ? `dh <br /> FA#: PR#: Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) 'K Containers (282 1) #of Containers: —` TA#: /9��/� <br /> (>250 gallons) >55 gallons and<250 gallons) .� <br /> Product Type: 1� b�l r ]� 7E Z S <br /> Total Capacity: �gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) X Containers (2821) #of Containers: LL TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: C�2Ur61J he 16 3d <br /> Total Capacity: 22, 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) gContainers (2821) #of Containers: TA#: <br /> 1>210 gallons) (>55 gallons and<250 gallons) <br /> Product Type: C�rBU!'O 11 ba l D 15-14-11) <br /> Total Capacity: 3 3 a gallons stall Date: <br /> (per tank or cumulative for container;by product type) <br /> ❑ Tank(2820) �6 Containers (282 1) #of Containers: 2 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: C�¢V r6i.1 TF 100.6 <br /> Total Capacity: 110 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers(2821) #of Containers: TAM 6 6 <br /> (>250 gallons) >55 gallons and<250 gallons) n <br /> 5 -2 Product Type: ,�. � T R'C. 86 �6 <br /> Total Capacity: 2 c> gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: O gallons Total Capacity for Site: Z gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: I 7i <br /> EHD 28-01 <br /> 01/16/08 <br />