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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMEN-t,. <br /> ' <br /> y "900 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> ,1 s r1fi iee,L U -z- LP Page of <br /> Facility Address � City: Inspecti <br /> AqAr: ,k >� Ij 010VA� /z) <br /> FA#• PR#: Program Element <br /> Z L4 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 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 Product Type: <br /> Total Capacity: 790. gallons <br /> (per tank or cumulative for containers by product type) Install Date:. <br /> ❑ Tank(2820) ❑ Containers (2821) r#of Containers: TAM(>250 gallons) (>55 gallons and<250 gallons), <br /> 2' Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAM <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: TAW: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons a <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 Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: V gallons Total Capacity.for Site: "� gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered. Date: <br /> � By Initial: ' �(p�0 By Initial: GY <br /> EHD 28-01 i <br /> 01/16/08 <br />