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SAN JOAQUIN COUNTY <br />?NVIRONMENTAL HEALTH DEPARTMEN' <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Weh: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Na e: <br />D ,1 1 TJQ Af � Q <br />PageJ-- of <br />Facility Address: // City <br />7 LRT <br />Inspecti7D./Ae p <br />v O o vgo jo <br />s O <br />FA #: <br />a oo �41j' <br />PR #: <br />16 Sz3 LI -W <br />Program Element: <br />7, 3 <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum > 1320 gallons in tanks and containers over 55 gallons. <br />Complete one box for each tank or each cumulative container product type. <br />nk (2820) Containers (2821) #of Containers: Z T_A_#: 6,S/ le <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: sD gallons <br />(per tank or cumulative for containers by product type) Install Date. <br />EV/Tank(2820) ❑ Containers (2821) #of Containers: TAM <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: Q <br />Total Capacity: % B 0 0 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: j`,15- 1 L, [ t5 <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: ZO &6 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: t -9,A) IP <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) M ^ <br />Product Type: <br />2,000 <br />Total Capacity:gallons : <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ' Containers (2821) #of Contai r #: to LAY <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product T <br />_ <br />Total Capacity: ! `L S gallons <br />Date: <br />(per tank or cumulative for containers by product type)Install <br />Total Capacity this Page: 2 6 Z S gallons <br />FTotal Capacity for Site: 6' Z gallons <br />Comments: <br />AVAvlzI L9- <br />J; N V d% 'l <br />=Zu ILA� ".W'. fiLf tl�)yI <br />EHD Inspector: <br />Reviewedte: <br />Enter Da�Zlz <br />By Initial: �—T?' <br />By Initial: <br />I <br />EHD 28-01 <br />01/16/08 <br />/!7 <br />