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_ SAN JOAQUIN COUNTY <br /> ' y�NVIRONMENTALHEALTHDEPARTMED`� <br /> bU0 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: / Q ) olVP y� Page Of <br /> Facility Address:f. L �1 V J-+ City: Inspecti Date• <br /> a v cNr-l�dkc� J <br /> FA#: PR#: Program Eleme <br /> 00 1 �g <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 (2821) #of Containers: TA#: <br /> I <br /> (>250 gallons) (>55 gallons and X250 gallons) Product Type: l✓A r T.F 6P/ <br /> Total Capacity: _57 CD gallons <br /> (pc 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 /> Product Type: /LjGTO/Zas- <br /> Total Capacity: 3 6a 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 /> 3 Product Type: /fJ�Jj A/V//f/Q,C-4�iC <br /> Total Capacity: 2—'I'D 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 /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: f ej O gallons 'Total Capacity for Site: 0 gallons <br /> Comments: <br /> Z- i Za — ln/R <br /> J <br /> EHD Inspector Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> EHD 2M I <br /> 01/16/08 <br />