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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMI <br /> �- 600 East Main Street,Stockton,CA 95202-'jw6 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility NUN/0 �1! /,/ /9, C/ .t±/G f /Av TEi-M d o19G �AC�GW)ry Page of <br /> Facility Address: � City: Inspecti D te: <br /> fio T /�:AIC R � '7 t o <br /> FA#: #: Program E meat: <br /> 00 roZ/ 6TFR7-3 3 rY - 3 v <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 /> �ank(2820) ❑ Containers (2821) #of Containers: TA#: (1916-/to 7 D 4' <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: 6—iri <br /> Total Capacity: .-P gallons Install Date: <br /> (per>1 <br /> or cumulative for containers by product type) <br /> JTank(2820) El Containers (2821) #of Containers: TA#: 7 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: V /V <br /> Total Capacity: .740y gallons Install Date: <br /> (pr tank or cumulative for containers by product type) <br /> ER/ <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM 51 ir 7 I <br /> I <br /> 3 (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: <br /> Total Capacity: S"'. a o gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> © Tank(2820) Containers (2821) #of Containers: �_ TA#: -7 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: 0 <br /> Total Capacity: Z o 6 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> r <br /> M Tank (2820) ❑ Containers (2821) #of Containers: TAM /IR <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: /I r 17 60 L I <br /> Total Capacity: 3 O gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: O d D gallons Total Capacity for Site: /07 ,5 gallons <br /> Comments: .7 ��%j Zj <br /> tF r <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> G i By Initial: kN4 By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />