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SAN JOAQUIN COUNTY <br /> i `moi.a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton;CA 95202-302 <br /> Mj <br /> Telephone:(209)46.8-3420 Fax.(209)468-3433 Web:www.sjgov.org/chd' <br /> fk r <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: ' <br /> CnN.`T'P, AC.TDAS fi of �►Tev� 5VC / NG Page of . <br /> Facility Address: ; Lo <br /> City: .� J� L lzispection ate: <br /> ao T z d <br /> FA#: PR#: ^^ '"J Program Ell <br /> [/ of / Z <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum.Z 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: TAMIf <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 / Product Type: <br /> Total Capacity: 3 b D gallons <br /> (per tank or,cumulative for containers by product type) Install Date' <br /> El Tank(2820) Lf Containers {2821) #of Contain s: A#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: +� gallons Install Datt�� <br /> (per tank or cumulative for containers by product type) _ <br /> ❑ Tank'(2820) R/C"Ontainers (2821) #of Con diners: 'ISA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product T . <br /> Total Capacity: 7_., gallons <br /> (per tank or cumulative foe containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <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 (2821) #of Containers: TAM <br /> (>250 gallons) ,o (>55 gallons and X250 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: S s'r gallons Tofal Capacity for Site.- SSS gallons <br /> Comments: J <br /> EHD Inspector: <br /> Reviewed Date: By teed Dates <br /> By Initial: By Initial: (Cy <br /> EHD 28-01 ' <br /> 01/16/08 <br />