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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTN <br />600 East Main Street, Stockton, CA 95202-3029 <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 />�- <br />� � <br />Page � of <br />�,; 1v� <br />i r.ck r <br />� i <br />Facility Ad r ss: City: <br />d .9G �� 1 T C <br />Inspecti <br />FA #: <br />C? g)p <br />PR #: <br />1 6u` -A913 <br />Program Element: <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 />Com Tete one box for each tank or each cumulative container product type. <br />❑ Tank (2820) Containers (282 1) #of Containers: '� TA#: 0514?ZfQQ <br />1 <br />(>250 gallons) (>55 gallons and Q50 gallons) � <br />Product Type: 77 FA A, Z/C <br />Total Capacity: T 7 gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) containers (2821) #of Containers: l TA#: 1-96-1 It P g f <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />� <br />Total Capacity: J-1 gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) Lf1 ontainers (2821) #of Containers: ` T #: <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />� <br />lr <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />R Tank (2820) ❑ Containers (2821) #of Containers: TA, .) 0511�[e <br />4Product <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Type: ✓ <br />Total Capacity: '3 So 62 gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />L]�I ank (2820) ❑ Containers (2821) #of Containers: TA#: <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: j' iL� 0 i <br />_zA/,q <br />Total Capacity: // sto v gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: C' b� gallons <br />Total Capacity for Site: Z gallons <br />Comments: g 3 3 - 417 60 <br />EHD Inspector: <br />Reviewed Date:__ll <br />By Initial: � 1r�10b <br />Entered Date: <br />By Initial: %Iqlk <br />EHD 28-01 <br />01/16/08 <br />