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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARW—" <br />600 East Main Street, Stockton, CA 9520, Jcy <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 />Pae Of <br />Facility Address: City: <br />Inspec ion Da <br />W <br />/'l'I/�n/T�c <br />51q <br />FA #: <br />000 98odI <br />PR #: <br />.Sis' <br />Program El e nt: <br />-2, <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 />8'�Tank (2820) ❑ Containers (2821) #of Containers: TA#:C; //2�� <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: �/i/ S <br />Total Capacity: gallons <br />-s0"�' <br />(per tank or cumulative for containers by product type) Install Date: <br />ER Tank (2820) ❑ Containers (2821) #of Containers: TA#: LA ie 012 % <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: Pu"Z)el <br />Total Capacity: .0 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />L? Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: SU o gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />00ank (2820) EP"Containers (282 1) #of Containers: TA#: �9,�/� <br />(>250 gallons) (>55 gallons and <250 gallons) <br />4 <br />Product Type: p <br />Total Capacity: z? 5 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />,?ATank <br />(2820) Containers (2821) #of Containers: TA#: Q5-/ A- -76' <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: 0/11 - <br />/ LiTotal <br />Total Capacity: // O gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: 97gallons <br />Total Capacity for Site: gallons <br />Comments: <br />EHD Inspector: <br />Co , i <br />Reviewed Date: f� <br />By Initial: VV.P� . ) X15• p <br />Entered Date:/� <br />By Initial: <br />EHD 28-01 <br />01/16/08 <br />