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SAN JOAQUIN COUNTY 1 <br /> -ENVIRONMENTAL HEALTH DEPARTMEi <br /> 000 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: r <br /> DIY4O ^/ S 7-4 1/ C-I l0 Page--Z--of <br /> Facility Address: J�v City: ` i Inspect'gn Dat <br /> �-�t U � Ae D <br /> .V1 <br /> FA#: PR#: Program El ent: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: T / <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: <br /> Total Capacity: - 6' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> D: ank(2820) ❑ Containers (2821) #of Containers: � -/JTA#: Le 5 77 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: c3 j <br /> Total Capacity: ..S,SU gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> �nk(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 - Product Type: d� <br /> Total Capacity: Y' -J—U gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Clank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 4 Product Type: <br /> Total Capacity: 1`f gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> �ank(2820) ❑ Containers (2821) #of Containers: TA#: 0 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: O/ 4�/ <br /> Total Capacity: P 5 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: = gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed (�� Date:3 1 Entered Date: <br /> By Initial: 1` I By Initial: �x <br /> EHD 28-01 7 �C7 <br /> 01/16/08 <br />