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64 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM <br /> 00 East Main Street,Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: / ,, <br /> AI 0/Q S / l/O�C Lcflf/W�r GD Page—L—of <br /> Facility Address: City: Inspection Jlate• <br /> FA#: PR#: Program Elem nt: <br /> o © 9 3 9 3 s'/6 Z2- <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 /> Complete one box for each tank or each cumulative container product <br /> ❑ Tank(2820) 9;�'l ontainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) ,. <br /> 1 Product Type: A T/' <br /> Total Capacity: nt f gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) Containers (2821) #of Containers: / TA#: <br /> < <br /> (>250 gallons) (>55 gallons and 50 gallons) � <br /> D <br /> 2 Product Type: (J'—w — <br /> Total Capacity: .SS gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: L951 Lvlo <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: O < [� <br /> Total Capacity: 4/ ZD gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ank(2820) ❑ Containers (2821) #of Containers: TAM a A 1 le(e Z t�- <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 4 Product Type: Dec <br /> Total Capacity: / 2-- o 0 t9gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> LYTank(2820) ❑ Containers (2821) #of Containers: TA#: B6-/ (e&144o <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: 4-AS7E O4 <br /> Total Capacity: � z-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 2 1 ,56 gallons Total Capacity for Site: Z gallons <br /> Comments: <br /> EHD Inspect of Reviewed Date: Entered Dale: <br /> By Initial: lkj By Initial: PC 4 2 <br /> EHD 28-01 l/ <br /> 01/16/08 <br />