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/ 90 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <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: <br />Page of --L-- <br />Facility Address: <br />�b ►J <br />-, <br />City. <br />�� <br />Inspe io Date: <br />-7 <br />6 <br />l <br />1 11 D <br />FA #: <br />PR #: <br />Program Element: <br />Z Z <br />28�n <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum Z 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) <br />#of Containers: ` � TA#: 9 <br />% <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />„� <br />Product Type:.��/,�q C� <br />Total Capacity: 1� gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) Containers (2821) <br />#of Containers: TA#: <br />Q ' <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: / © 9 O gallons <br />(per7k or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />3G <br />(>250 gallons) (>55 gallons and <250 gallons) <br />2C> <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) Containers (2821) <br />#of Containers: TA#: <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />� <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />MAI LIZI <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: -75 gallons <br />Total Capacity for Site: <br />G% 7S gallons <br />Comments: <br />¢r <br />All Aje3A'tr=L <br />EHD Inspector: <br />Reviewed <br />By Initial: <br />Date: { <br />wt")(D-i 0'0 `f <br />Entered <br />By Initial: <br />Date: <br />!� t% <br />1"k) / v/ 7/ lo <br />EHD 28-01 <br />01/16/08 <br />