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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME. _ <br />600 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 Name: <br />`}/y <br />Page I of <br />F, Co <br />Facility Address:// <br />10 1 C) <br />City: �j <br />Inspect'on Date: <br />FA #: E <br />S2 <br />PR #: <br />'?R,9 <br />5a77 <br />Program Ele ent: <br />83 <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) <br />#of Containers: TA#: <br />1 <br />(1250 gallons) (>55 gallons and <250 gallons) <br />Product Type: �/ G>,.5�, <br />Total Capacity: �D gallons <br />'> <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />, <br />'KTTank(2820) Containers (2821) <br />#of Containers: TAM a 51558 <br />2 <br />250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />Install Date: 6* --4y2& 00-z <br />iS <br />(per tank or cumulative for containers by product type) <br />El Tank (2820) IX Containers (2821) <br />Ci47Yt <br />#of Containers: � TA#: p <br />5)5'86i5l <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />—� � <br />Product Type: <br />Total Capacity. gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) tKContainers (2821) <br />#of Containers: T <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />,/ <br />Product Type: /,(�(�-P Gf O <br />Total Capacity: (�5 O O gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />T( 2820) ElContainers (2821) <br />#of Containers: TAM(> <br />5 <br />50 gallons) (155 gallons and <250 gallons) <br />Product Type: O / / �C/% a /f' <br />/G( .) J <br />Total Capacity: —7D_ gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: (02o gallons <br />Total Capacity for Site: <br />5V2D gallons <br />Comments *2 t( <br />D/ k a <br />\ � 6 wv <br />r - <br />#4 Ifo /sdf eiLd);2a-� <br />.(' <br />EH ector: <br />Review <br />By Initial: <br />ate: <br />2 �l ((�� <br />ntered <br />By Initial: <br />Date: <br />EHD 28-01 <br />01/16/08 <br />G <br />