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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENIM <br /> 0 East Main Street, Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Nsme:?0 C 4,1 <br /> Page of <br /> Y U U f 2 2 <br /> Facility Address- City: Inspection Date: <br /> 908 S . C W6kee C.N- (6i C,4 9-P�; <br /> FA#: PR#: Program Element: <br /> F- O6 io�'ll l9�ae 7151 <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 /> ❑ Tank(2820) [O Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: ��W tEb of <br /> Total Capacity: _gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) D Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: qaw ai <br /> Total Capacity: A0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 129 Containers(2821) #of Containers: TA#: O5J 7 ),667 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 In � Product Type: t0 W 36a�f <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<50 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: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: O <br /> EHD 28-01 <br /> 01/l6/08 <br />