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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <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 Nar•-- i✓ ,Page of <br /> IAIZAAf <br /> Facility Address: i , %_Ity: Inspecti Date, <br /> !!H7A0_ k� 11,WZ, U2 g�L <br /> 3 � b $ <br /> FA#: � R� � � � Progr <br /> Pm�l <br /> Tank/Container Information 2 <br /> Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. <br /> Com ete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) Containers (2821) #of Containers: 3 TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 / � � Product Type: �//�f n/� 0/ <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Zecontainers (2821) #of Containers: s�� TA#: <br /> (>250 gallons) (>55 gallons and X250 gallons) // <br /> 2 Product Type: Ly o�L A LL f/ Q <br /> Total Capacity: / 6,S gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) R Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: �yjl�' /all d J <br /> Total Capacity: 5 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 0 C ontainers (282 1) #of Containers: ` TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 4 Product Type: y pf�lf <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> in <br /> ❑ Tank (2820) LYContainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: /ti!,q C/I/'V <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons FTotal Capacity for Site: gallons <br /> Comments: <br /> �O <br /> _T <br /> 93a <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> s d By Initial: to-A-0 By Initialklf ip <br /> EHD 28-01 <br /> 01/16/08 <br />