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SAN JOAQUIN COUNTY <br /> ,:NVIRONMENTAL HEALTH DEPARTMENT <br /> 600 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: F�d �� �V4WAl Page '— Of <br /> Facility Address: Ci Inspection Date: <br /> 'b N OU& L <br /> FA#: UY PR#: Program Element: <br /> `I LLK 72€3� <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks*and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> ank(2820) <br /> El Containers (2821) #of Containers: TAM &e,ao �q <br /> 1 ` <br /> gallons Product Type: d'i <br /> otal Capacity: <br /> (per tank or cumulative for containers by product type) Install Date: Lx -)r,c.4. ") <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: r gallons Product Type: 81M <br /> (per tank or cumulative for containers by product type) Install Date: UM� <br /> ank(2820) ❑ Containers (2821) #of Containers: "STA#: e <br /> 3gallons <br /> Product Type: <br /> rota Capacity: g <br /> (per tank or cumulative for containers by product type) Install Date: UN k-M cy N <br /> �11Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> 4Product Type: �sn <br /> Total Capacity: lob gallons <br /> (per tank or cumulative for containers by product type) Install Date: v4,'zWqN <br /> Tank(2820) El//Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: vU gallons Product Type: i <br /> (per tank or cumulative for containers by product type) Install Date: ( v <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered <br /> ILI <br /> Da <br /> By Initial: (zo+ 02 �� By Initial: J <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gal ons or more of petroleum. ` <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 <br />