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SAN JOAQUIN COUNTY <br />3NVIRONMENTAL HEALTH DEPARTMEN' <br />b00 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />4 <br />�BOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Na e: <br />4 / %JQ Af y� o <br />Page of <br />Facility Address: City: <br />00 - OT Rd- LRT ie <br />Inspecti D e:. <br />st/��hql, <br />FA #: <br />PR #: <br />6Iz-3 441 <br />Program Element: <br />z 3 <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 />pOTNnk (2820) Containers (2821) #of Containers: Z TA#: /p <br />1 <br />(>250 gallons) (>55 gallons and QSO gallons) <br />Product Type: <br />Total Capacity: ,S"i% gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Tank (2820) ElContainers (2821) #of Containers: TA#: <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Type: <br />� c7Product <br />Total Capacity: � � � gallons � . <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: j� ) le [ � <br />(>250 gallons) (>55 gallons and <250 gallons) <br />3 <br />� Zo &6 Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />ff�Tank (2820) ❑ Containers (2821) #of Containers: TA#: 69A) [P <br />(>250 gallons) (>55 gallons and <250 gallons) r <br />4 <br />2 0 10 Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) Containers (2821) #of Contaiurr_#: (Q <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />25 C-5 Product T _ (✓ <br />Total Capacity: gallons <br />Install Date: - <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: 6' gallons I <br />Total Capacity for Site: gallons <br />A)Av91 C-,< F3JV",r'rP _ c� �' 2 6RJ S- <br />ocNy DJC IC//i <br />EHD Inspector: <br />�LL(� — �f '� �� <br />Reviewed te: <br />By Initial: y <br />Entered Dak: <br />By Initial: Q <br />EHD 28-01 <br />01/16/08 <br />