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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN' <br />600 East Main Street, Stockton, CA 95202-30�-. <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 />L' I %lQW e9r� 6 <br />Page of <br />Facility Address: City: <br />00 Ro7-11 k6t. LR <br />Inspecti D e:. <br />19-- Tj� ie <br />FA #: <br />PR #: <br />6 1 a Z/ <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 />(2820)on alners (2821) #of Containers: TAM' <br />1 <br />(>250 allons) (>55 gallons and Q50 gallons) <br />Product Type: <br />Total Capacity: ,S D gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Tank (2820) ❑ Containers (2821) #of Containers: TAM <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: / '-4?0 0 0 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) ##of Containers: TAM <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: ,–ami <br />Total Capacity: 17-0 &6 gallons [ <br />(per tank or cumulative for containers by product type) Install Date: <br />Tank (2820) ❑ Containers (2821) #of Containers: TAM �h) 1P 1� j <br />42 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />0 0 <br />Total Capacity: I 0 gallons � <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) Containers (2821) #of Contai #: Lp <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) �� <br />Product T <br />� <br />Total Capacity: gallons Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: 8gallons <br />Total Capacity for Site: r gallons <br />Comments: <br />Q <br />l')A191 C -r 3 9 <br />rIVV a'b�IG/c-/i <br />%40 D <br />EHD Inspector: <br />Reviewed te: <br />By Initial: y <br />Entered Da : <br />By Initial: �y B <br />EHD 28-01 <br />01/16/08 <br />