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SAN JOAQUIN COUNTY <br /> 'NVIRONMENTAL HEALTH DEPARTMENI � <br /> X600 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 lv e: <br /> d V N N 6:- Gp• l ffC- Page of <br /> Facility Address: City: Inspection ate: <br /> 21So (11 vs � M1'Tr- /9Vr' MAof''FC-R <br /> FA#: PR#: Program EIeme t: <br /> z ©5a$te 16— <br /> Tank/Container zoo <br /> 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: TA#: <br /> 0250 gallons) (>55 gallons and<250 gallons) - <br /> 1 Product Type: �/9 SAF O/ L <br /> Total Capacity: 6 p gallons <br /> �(p�r tank or cumulative for containers by product type) Install Date: <br /> IJ' Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) r <br /> 2Product Type: r L. <br /> Total Capacity: 0 D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) IR Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: 55 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> El Tank(2820) Q'Containers (2821) #of Containers: ?/ TA#: <br /> (>254 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: -,zl o>"DyL. p r- C--,/ <br /> Total Capacity: // R 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 /> 5 Product Type: �Yl !> 12la L l �/ � <br /> Total Capacity: 2- ST gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: v gallons Total Capacity for Site: 9 z� gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: �„� `�,�,Q� By Initial: 1 Q <br /> EHD2"I [ <br /> 0[/15108 <br />