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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 /> CON' O .moi 7�eD C oAl'?'AIA4✓ 1� C- 17 Page l of <br /> Facility Address: City: Inspectio Date <br /> FA#: PR#: Proggam EI ent: <br /> D5a<a& 3 2$ D <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) Q/Containers (2821) #of Containers: 3 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: �.f Y z-2A A L i G 1 <br /> Total Capacity: r gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Elt5ontainers (2821) #of Containers: Y TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: 4-L'n/2 <br /> Total Capacity: `/ 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3Product Type: �p TD�Z. 0` <br /> Total Capacity: ,�s gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) vContainers (2821) #of Containers: l TA#: <br /> 4 <br /> (>250 gallons) (>55 gallons and<250 gallons)„f� Product Type: AIA rz� , <br /> , <br /> Total Capacity: .� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 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: gallons Total Capacity for Site: g gallons <br /> Comments: <br /> EHD Inspector: Reviewed I Date: Entered Date: <br /> By Initial: 1 l AV '0"_0j <br /> By Initial: lef! <br /> EHD 28-01 WWWfe <br /> 01/16/08 <br />