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USAN JOAQUIN COUNTY <br /> z � 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 /> -Ilyyj <br /> rte- / (/ i� /4 ,5 5�� /y`� g <br /> 1�,,/ r ` �( Pae f of <br /> Facility Address: Cit :Z- inspectio )ate, <br /> �=!AlDgpd /0 ) 61T <br /> FA# PR# Program Element: <br /> 06 ' -z-9'fj <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 /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 <br /> 300 Product Type: P ,> <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) ontainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 2 Product Type: �r/*< Ao�F 01 � - - <br /> Total Capacity: //0 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 /> 3 Product Type: <br /> Total Capacity: 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 450 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for contaiiiers by product type) install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 0250 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: 'P'VD gallons Total Capacity for Site: gallons <br /> Continents: <br /> 13 2-b d <br /> EHD Lnspector: Reviewed Date: Entered Date- <br /> By initial: It�,fl� By Initial: r Q <br /> EHD 28-01 [ 1 <br /> 01/16/08 <br />