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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN'j_ <br /> 600 East Main Street, Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: r� g <br /> S`70 / P157 1460 a. ��.�, I Pae of <br /> Facility Address: City: nspection D te:�/ <br /> Joir <br /> FA#: PR#: Program Element: <br /> -S <br /> Tank/Con' tainer Information <br /> 4 Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAO: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: 7is�. /Ne �f <br /> Total Capacity:. y.7-� 41- gallons . <br /> (per tank or cumulative for containers by product type) Install Date: <br /> OP/Tamk(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 7'"� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> PTank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type; <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date-. <br /> PTank(2820) El Containers (2821). #of Containers: TA#: <br /> (>250 gallons) (>55'gailons and'<250 gallons) ` <br /> 4 Product Type: !�!/NF r1.�7 G : + (� of L <br /> Total Capacity: 3. gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: —.• <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date- <br /> Total Capacity this Page: D `� gallons TTotal Capacity for Site: 6r gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date:� Entered Date: <br /> By Initial: l'<J`��� By Initial: ; <br /> EHD 28-01 <br /> 01/16/08 " ' <br />