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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 Weh:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> / !�oO/% rZ 12,9 Z-A 11GKIAJ Ir0 Page-L--of <br /> Facility Address: <br /> City: Inspec['on Da <br /> 2) VY <br /> FA#' PR# Program Eleme t: <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 type. <br /> Elo'fank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 U d Product Type: p/ (� <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> lank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: SO d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Elai/ <br /> Tank(2820) al Containers (282 1) #of Containers: TA# <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 3 Product Type: �- <br /> Total Capacity: .-J gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> El Tank(2820) aContainers (2821) #of Containers: TA#: 19� -7 9-4p <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: �r <br /> Total Capacity: r / gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 5VKontainers (2821) #of Containers: TA#: dL!�T-!'7,�/X <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 �Total CapProduct Type: ��(/)q <br /> a�'ty: Z U D gallons <br /> (per tank or emu r containers by product type) Install Date: <br /> Total Capacity this Page: 7i 0 gallons Total Capacity for Site: Z 2/Q gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: '/ Entered Da[e <br /> By Initial: �(.� Cd-'ylc-p`l By Initial: 7 <br /> EHD 28-01 <br /> 01/16/08 <br />