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SAN JOAQUIN COUNTY <br /> • 0 ENVIRONMENTAL HEALTHDEPARTMEi* <br /> 600 East Main Street,Stockton,CA 95202-3b'..d <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: Q Gv�/ �'�yr" ,gi•' Page IL" of <br /> kk , v <br /> Facility Address: City: Inspection Date- <br /> ( 02 l (D <br /> FA#: PR#: Program Element: <br /> Fief o �i age <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 /> Cou4lete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) Containers (2821) #of Containers: l T,A#;IP5--Z/�7�ttr7 - <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: gallons <br /> (per tank or or eulative for containers by product type) Install Date: <br /> 0, If k(2820) ❑ Containers (2821) #of Containers: T� <br /> (>250 gallons) (>55 gallons and<250 gallons) �r -- <br /> 2 Product Type: (r!1 J <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> L+Y Tank(2820) ❑ Containers(2821) #of Containers: TA#. <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per took or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 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: TA#: <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: gallons Total Capacity for Site: �Z gallons <br /> Comments: <br /> ZZO <br /> EHD Inspector: ReviewedL •D 4 Entered Date <br /> By Initial: RV" �` .J By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />