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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTM' <br />600 East Main Street, Stockton, CA 95202-�„zy <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 />1�NS� ! /i'1 %3(/`�6DN l S� <br />Page of <br />Facility Address: �+ City: / n /�/j <br />Inspect' n Dat <br />FA #: <br />IS' <br />PR #: <br />Z3 <br />Program Element: <br />2y3-,' <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) E"Containers (2821) #of Containers: <br />1 <br />-A#: <br />(>250 gallons) (>55 gallons and <250 gallons)�'�� - <br />Product Type: Q,��.a-C'J <br />Total Capacity: 2- FO gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) Containers (2821) #of Containers: TAM b f [p ? <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />1-7,9 Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) [Et/Containers (2821) #of Containers: TAM /96-/ '7 40 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />3 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Q" Tank (2820) ❑ Containers (2821) #of Containers: TA#: a 1 Le 7 � / <br />(>250 gallons) (>55 gallons and Q50 gallons) �- <br />4 <br />Product Type: <br />, <br />Total Capacity: A,700 0 gallons � <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) Containers (2821) #of Containers: TA#: <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />' 7 -�' Product Type: _ <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: "✓ gallons <br />Total Capacity for Site: 5 6 f gallons <br />eafl <br />Comments: /67 4 v/1 e 4---o sCAl S o Al g 3 9' LAC, <br />34: <br />71,7AIA <br />_ <br />Tyr -sem 7-A CaN r �� , <br />a -, % F I- wK U fc pt, q r/W <br />f S <br />EHD Inspector: _94� <br />�`��"�(� <br />Reviewed Date: <br />By Initial: � (P. �� <br />Entered Da e: <br />By Initial:1,4 <br />EHD 28-01 <br />01/16/08 <br />0 <br />