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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMEN*M/ <br /> 600 East Main Street,Stockton,CA 95202-302y ' <br /> Telephone:(209)468-3420 Fox:(209)468-3433 Web:www.sjgov.orglehd <br /> ABOV GR UND PETROLEUMSTORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> Page of <br /> Facility Address: City: Inspec'on At <br /> 303 So <br /> S . i c-y 091 6 <br /> FA#: ?/ q7& I PR#: Pro ram E menti T— <br /> &6-7 - <br /> & - - W6- <br /> Tank/Container <br /> 6Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> 91fank(2820) ❑ Containers (2821) #of Containers: TA#: r9 <br /> (>250 gallons) (?$& f2/'ga�q�nd<250 gallons) \ <br /> 1 6%+At�[/ Product Type: / <br /> Total Capacity: tons � <br /> (per tank or cumulative for co rainers by product type) Install Date' <br /> Tank(2820) ❑ Containers (2821) #of Containers: — TA#: ASS u`l <br /> (>250 gallons) (>55 gallons and<250 gallons) _ <br /> Z Product Type: QAJ <br /> Total Capacity: gallons l� a�� L11 62 0i I sfi � <br /> (per tank or cumulative for con ers y product type) Install Date: <br /> Tank(2820) ❑ Containers(2821) #of Containers: TA#: f.Z 1�a2�c57q <br /> (>250 gallons) (>55 gallons and<250 gallons) mow^ <br /> 3 Product Type: IVIA�'Ij <br /> Total Capacity: —gallons <br /> (per tank or cumulative for containers by product type) Install Date: _b?�d4j. - <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: �P&j4p <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: kAr <br /> Total Capacity: 11 gallons Install Date: l.r rijod t I ,,.r l u l� dz Rep, <br /> (per tank or cumulative for con byproduct type) - l <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: B'5.jO t5$ l <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: (J4,,04 tyl <br /> Total Capacity: _ gallons QLP <br /> (per tank a cumulative for con ret by product type) Install Date: f k <br /> Total Capacity this Page: rM gallons Total Capacity for Site: gallons <br /> Comme T n fr <br /> o-13- <br /> EHD Inspector: Reviewed Dale: x Entered Date: <br /> C- By Initial: O V By Initial: (Z! <br /> EHD 28-0I 51 z,1 1� •/ 1 I J <br /> 01/16/08 '"l <br />