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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <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 />L <br />Page � of l <br />a r <br />Facility Address: <br />citk, <br />Z�a <br />Inspection Date: <br />Zi/ .� • v <br />P l <br />101 <br />FA #: <br />/ 0 0 <br />PR #: <br />o5�y� <br />Program Element: <br />�8 3 <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 type. <br />V"fank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: Q, 1 5,-� <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: 4//y <br />Total Capacity: .? gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) Containers (2821) <br />#of Containers: 3 <br />TA#: <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: �! d <br />jcJ 1? it f <br />Total Capacity: � �,� gallons <br />Install Date: <br />_ <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) IrC- ontainers (2821) <br />#of Containers: / <br />TA#: <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />/ <br />Total Capacity: s gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) �.ontainers (2821) <br />#of Containers: <br />TA#: <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: ?21d7_&/Z,' <br />Total Capacity: IS gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />ank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: &16_1 <br />$ <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />\ <br />Total Capacity: j o O gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: 2-11-5 j <br />gallons <br />Total Capacity for Site: -2,12, > gallons <br />Comments: <br />_T <br />EHD Inspector: <br />I- <br />Reviewed Date: , <br />By Initial: Vv" q >t U <br />q <br />Entered Date -/y <br />By Initial: �J l <br />EHD 28-01 <br />01/16/08 <br />