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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 East Main Street,Stockton,CA 95202-302 <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 /> C��✓T�qG l//�/GLl6 J" /5`Oq//d Page —�—of <br /> Facility Address: �/ % Ci[y: Inspect'�D�[e>O <br /> FA#: PR#: Pro�tgyram Element: <br /> 1 -2- 230 05o2S 2 d 3 Z/ <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 /> ER"Tank(2820) ❑ Containers (2821) #of Containers: TA#: yN�y'�'� <br /> (>250 gallons) (>55 gallons and<50 gallons) Product Type: <br /> e: D� l� <br /> 1 � <br /> Total Capacity: 2.od a gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: A57)1/3"7 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: 4't-4 <br /> Total Capacity: 3,000 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 12d Tank(2820) ❑ Containers (2821) #of Containers: TA#: D5 ) <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: /��lyos,QJ <br /> Total Capacity: O Ov gallons <br /> (per or cumulative or containers by product type) Install Date: <br /> EM/Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q ,lJ <br /> 50 gallons) r, �— <br /> 4 Product Type: .c� 01 J <br /> Total Capacity: //1,7,;?4 tj gallons <br /> (per tank or cumulative for containersproduct roduct type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: Z J O(/Q gallons <br /> Comments: <br /> N 6: Go 9. Nf---IL Sw/Y j STa r6 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: $ 70� <br /> EHD 28-01 VVV <br /> 01/16/08 <br />