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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMi <br />600 East Main Street, Stockton, CA 95202 -30 - <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name: /A/ y 1011-1d <br />Page _ ofl <br />Facility Address: <br />City: <br />Inspectio Dae: <br />FA #: <br />PR #: <br />Program Element: <br />D <br />S12 <br />1�61-QFCQ- <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 />ConVfete one box for each tank or each cumulative container product type. <br />❑ Tank (2820) Containers (2821) <br />#of Containers: 4 TAM j <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />lube 1/ <br />Total Capacity: 7. 10 gallons <br /> <br />Link nk or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) Containers (2821) <br />#of Containers: <br />TAM <br />2-� <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: rj gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) Containers (2821) <br />#of Containers: <br />fq"5-1 ze <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />► l� <br />Total Capacity: gallons <br /> <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) containers (2821) <br />#of Containers: TAM lP p <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />ikEA#gallons <br />Product Type: <br />Total Capacity:1W <br />.' <br /> <br /> <br /> <br />❑ Tank (2820) P Containers (2821) <br />#of Containers: <br />TAM <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />[ <br /> <br /> <br /> <br />Total Capacity this Page: 3 gallons <br />Total Capacity for Site: gallons <br />Comments: <br />3 <br />EHD Inspector:41� �� ( <br />Yr oil <br />I <br />Reviewed <br />By Initial: <br />Date: <br />h <br />Entered Date: <br />By Initial: <br />& � <br />7, <br />EHD 28-01 <br />01/16/08 <br />