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X ( <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME <br />600 East Main Street, Stockton, CA 95202 -3(, - <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 />57A �IA <br />r� <br />�`s C5 �1/J� <br />Page Z of�_ <br />Facility gess: <br />v <br />City: <br />'JVn� <br />Inspec;7 1 D te:, <br />FA #: <br />PR #: <br />Program ement: <br />o <br />2ga <br />Tank/Container Information <br />Complete for all sites with cumula ' e aboveground <br />storage of petroleum Z 1320 gallons in <br />tanks and containers over 55 gallons. <br />Co ete one box for each tank or each cumulative container product <br />type. <br />❑ Tank (2820) Containers (2821) <br />#of Containers: TA# �51 1E 5� <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: %T20'L <br />j <br />0_ <br />Total Capacity: //,9 g <br />- <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank 2820 LkCont ' 2821 <br />( ) ) <br />2 <br />#of Containers:L z TA#: 0±5 (p � <br />2 <br />(>250 gallons) (>55 gall s allons) <br />Product Type: <br />Total Capacity: allons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />_. <br />[r ank (2820) ❑ Containers (2821) <br />#of Containers: TAM F <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Z.. � � a <br />Total Capacity: % gallons <br /> <br />l <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: T -A#: T <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: 0 O 4!�) gallons <br /> <br />(per tank or cumulative for containers by product type <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TAt (e 1 <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: 1-2-00e) gallonso <br />�& <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: 3 �p Zr� d gallons <br />I Total Capacity for Site: <br />O gallons <br />Comments: <br />EHD Inspector: O 11 <br />Reviewed Date: <br />By Initial: <br />0 1t <br />Entered D e <br />By Initial: <br />I <br />1J� <br />EHD 28-01 <br />01/16/08 <br />