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SAN JOAQUIN COUNTY <br /> - •ENVIRONMENTAL HEALTH DEPARTMENO <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 /> " U D 4- �v P4 T-/lC Page—V—of <br /> Facility Address: City: Inspect' Da <br /> li 2� tines 4f o -3 Date16 8 68 <br /> FA#; �• PR#: Progranit Element: <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) Containers (2821) #of Containers: L _ TAM <br /> (>250 gallons) >55 gallons and<250 gallons) <br /> 1 . Product Type: <br /> Total Capacity: 2 10 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) IN Containers (282 1) #of Containers: TA#: fJSJ!' 5� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: /1/l D�1 <br /> Total Capacity: 1 (--� 1� gallons stall Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) 1Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: (' t`N S ►t�L SC)(� <br /> Total Capacity:��gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> �G ❑ Tank(2820) Containers (282 1) #of Containers: 2 TAM <br /> (>250 gallons) (5,55 gallons and<250 gallons) <br /> /f Product Type: CtjeUr03.J n /¢(a 4d(> �3U <br /> Total Capacity: 1 [ 0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) Containers (2821) #of Containers: 2 TA#: _6-?`x-3 <br /> (>250 gallons) 55 gallons and<250 gallons) <br /> Product Type: C A M GO — ] l —j <br /> Total Capacity: 11�gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Zo gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By initial: I <br /> 71D I-- <br /> EHD 28-01 <br /> 01/16/08 <br />