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SAN JOAQUIN COUNTY <br /> E(0NVIRONMENTAL HEALTH DEPARTME4 <br /> East Main Street, Stockton,CA 95202-30 <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 /> 'f/ LA GO Page of=�— <br /> Facility Address: City: Inspection Date: <br /> FA#: PR#: Program Element: <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 /> ❑ Tank(2820) Containers (2821) #of Containers: I TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 1 v Product Type: �-Itit(�itr �� <br /> Total Capacity: 2, <br /> (per tank oremulative for conte' by productgalpe) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: / TA#: ah-VeO/5 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: 0� <br /> Total Capacity: �gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ontainers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 � Product Type: ' <br /> Total Capacity: / '7 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Er-Containers (2821) <br /> / - <br /> ❑ Tank(2820) -ontainers (2821) #of Containers: �y TA#: .Z <br /> (>250 gallons) (>55 gallons and<250 gallons) Type: r <br /> 4 Product T e: <br /> Total Capacity: Ila gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: ?5 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 r" <br /> Product Type: A1A S'Z� O! <br /> Total Capacity: '-7- � gallons <br /> 41 <br /> (pet tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: B gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed ,� nDate: Entered Date: <br /> W <br /> By Initial: IJ By Initial <br /> EHD 28-01 <br /> 01/16/08 <br />