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r <br /> SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTMEN— ~ <br /> X600 East Main Street, Stockton,CA 95202-30sp� <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> XA -- i/ b OT0 S Page of <br /> Facility Address: City: InspTflo <br /> n Da <br /> 3 S Al FC r f7Al <br /> FA#: PR#: Program Ele ent: <br /> C)go 4D <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 2roduct type. <br /> Tank(2820) ❑ Containers (2821) #o f Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: -3 O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [i] Tank (2820) al ontainers (2821) #of Containers: TAM <br /> (>250 gallons) (>SS gallons and Q50 gallons) �.. <br /> 2 Product Type: ��` <br /> Total Capacity: /' Z 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 0250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: O/ �,-/ <br /> Total Capacity: 67 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 /> 4 Product Type: &,Ig�j'� Q � <br /> Total Capacity: -�S gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: <br /> 0250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: 0 � <br /> Total Capacity: / -z-6 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: / 21 j gallons Total Capacity for Site: f 2i5­0 gallons <br /> Comments: <br /> x/,_ / 3Z0 ,s' 1PIACTIVY <br /> EHD Inspector: Reviewed Date: EnteredMe <br /> DatBy Initial: � .1 {,� By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />