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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENTv <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 /> 50- C V 6 6 c, vRK S UT/ Li - $`S A+'- Page of <br /> Facility Address: Qty: I} v Inspection ate•�� <br /> v� G?' Z <br /> FA#: /0 PR#: Program Elepre <br /> 6 Z <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2,1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product <br /> 15-'Kank(2820) ❑ Containers (2821) #of Containers: •TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) n <br /> 1 Product Type: arca / <br /> Total Capacity: 2 S© gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons <br /> (per rank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 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: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> S Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: Z �j O gallons Total Capacity for Site: �j�sj'j gallons <br /> Comments: <br /> I <br /> EHD Inspector: Reviewed Date: Entered ^ Dat;: / <br /> C By Initial: t?'10 By Inti �oL <br /> EI-1132"l <br /> 01/1N08 <br />