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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMI <br />600 East Main Street, Stockton, CA 95202-3u19 <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 />5A <br />�( <br />Eg�VA <br />� r <br />INS r � 41%� <br />Page Z- of <br />Facility Address: <br />City: <br />Inspecti D te: <br />FA #: <br />PR <br />#: <br />Program lement: <br />93 2 <br />Tank/Container Information <br />Complete for all sites with cumulakive aboveground <br />storage of petroleum ;2-1320 gallons in tanks and containers over 55 gallons. <br />Co ete one box for each tank or each cumulative container product type. <br />❑ Tank (2820) <br />Containers (2821) <br />#of Containers: TA# Q lP 5� <br />1 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: <br />//tq gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) <br />l k -Containers (2821) <br />#of Containers: % TA#: <br />2 <br />(>250 gallons) <br />(>55 gallons and X250 gallons) <br />_ <br />Product T e• <br />yp�'��� <br />---�7 <br />Total Capacity: <br />Z-, d gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />L?'Tank (2820) <br />❑ Containers (2821) <br />#of Containers: TA# <br />ZIP&R7 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />3 <br />Total Capacity: <br />% Z � � � <br />Product Type: <br />gallons <br />Install Date: <br />(per tank or cumulative <br />for containers by product type) <br />Tank (2820) <br />❑ Containers (2821) <br />#of Containers: T-#: <br />V'? <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />4 <br />Total Capacity: <br />0 O i> gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) <br />❑ Containers (2821) <br />#of Containers: _ TA#: 119 lz�9 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />5 <br />/' Z 0 a <br />Product Type: _ ( <br />Total Capacity: <br />gallons <br />Install Date: <br />(per tank or cumulative <br />for containers by product type) <br />Total Capacity this Page: <br />3 3 0 <br />gallons <br />TTotal Capacity for Site: <br />gallons <br />Comments: <br />EHD Inspector: <br />Reviewed Date: <br />Entered <br />Date - <br />By Initial: <br />By Initial: <br />k&k fq 4) <br />EHD 28-01 <br />01/16/08 <br />