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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 000 East Main Street,Stockton,CA 95202-3025 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: � <br /> C-0 b4-110 A tl Page Z of <br /> Facility Addij e City: Inspection <br /> C.,LAY Sr <br /> FA#: ^ PR#: Program'E-le��njtent: <br /> S3 37 <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) El Containers (2821) #�ofContainers: TA#: D�/(PT!C <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: ry—OWL DI Z/ <br /> Total Capacity: �_gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ,Containers (282 1) #of Containers: TA#: 2 <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 2 Product Type: I �S5 OI Gli1 UY1I <br /> Total Capacity: 5�(� <br /> (per tank or cumulative for containers by product type) Install Date: —� <br /> X Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: to 'CAc_ O <br /> Total Capacity: 52Q 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 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<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: - 2�5—o gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Ins Reviewed y^� Date: (� II Entered Date <br /> By Initial: U I -` l\ By Initial: `( <br /> EHD 28-01 l <br /> 01/16/08 <br />