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SAN JOAQUIN COUNTY <br /> ,.{ENVIRONMENTAL HEALTH DEPARTMENT <br /> �. ' <br /> 00O East Main Street,Stockton,CA 95202-302� <br /> Telephone:(209)468-3420 Fac.(209)468-3433 Web.www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> tt �L <br /> Page of <br /> Facility Address: City: Inspection Date: <br /> 1 $OU lJ �r�w rte, S <—Z--- -& k b 1-31 v <br /> FA#: PR#: Program Ele ent: <br /> FAtx�o03'� 1 �5a�S'l,g42_ Z5S3 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product <br /> Tank(2820) ❑ Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) ' <br /> 1 Product Type: cQ{erg <br /> Total Capacity: `��o gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ,R,Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9s�/*?!I j 7 <br /> (>250 gallons) (>55 gallons and<250 gallons) T <br /> 2 Product Type: <br /> Total Capacity: / 00 o gallons <br /> (pa tank or cumulative for containers by product type) Install Date: <br /> -F!Z Tank (2820) ❑ Containers(2821) #of Containers: TA#: 6 Sl`7 zli ' FS' <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: oPl�se, l <br /> Total Capacity: 3 2-5' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> N1 Tank(2820) ❑ Containers (2821) #of Containers: TA#: /�,h /7 q L49 <br /> (>250 gallons) (>55 gallons and<250 gallons) —� <br /> 4 Product Type: �Qics�l <br /> Total Capacity: ->ZS gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1!7 1) 60 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: cQ,ea e. / <br /> Total Capacity: `�77 �O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 94 �j'p gallons I Total Capacity for Site: c-, gallons <br /> Comments: <br /> EHD Reviewed Date: Entered Date: <br /> By Initial: 0-114 By Initial: ie <br /> EHD -01 <br /> 01/16/08 <br />