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SAN JOAQUIN COUNTY <br /> E0NVIRONMENTAL HEALTH DEPARTM' <br /> East Main Street,Stockton,CA 95202-302 <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 /> A/✓T/% Page L—of 3 <br /> Facility Address: City: Inspecpon gate: <br /> 2/0 U25721-20A-0 M i✓T S/z /° � <br /> FA#: PR#: Program Element: <br /> coo �/ .TZt3Aj 1-S?3y <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 /> ank (2820) ❑ Containers (2821) #of Containers: TA#: �f Le �'f� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 �� <br /> Total Capacity: l o�, o o a gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> punk(2820) ❑ Containers (2821) #of Containers: TA#: !� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: /b O e U gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 11 Tank(2820) C5"Containers(2821) #of Containers: TA#: OcQ (e oZ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) 1ryi ;ontaincrs (2821) #of Containers: J TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: 0 ! <br /> Total Capacity: -- gallons Install Date: <br /> (per tank or cumulative for contamers by product type) <br /> ER'OfLk(2820) ❑ Containers(2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5Product Type: <br /> Total Capacity: ro o gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 2Q 1 p gallons Total Capacity for Site: 2- / gallons <br /> Comments: <br /> /w -Y ;B !o ix 10mevM <br /> END Inspector: C—451 <br /> Reviewed Date: Entered Date: <br /> l�� t By Initial: �,N 5 XI By Initial: / <br /> EHD 28-01 <br /> 01/16/08 <br />