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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME <br />600 East Win Street, Stockton, CA 95202-30L9 <br />Telephone: (209) 468-34-20 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name: nlyt � ,L{ n/ N <br />—h U 1 <br />/t l/%� �/ <br />�' <br />�Y / <br />Page of <br />Facility Address: <br />?W � ?� - t U�%L <br />City: <br />f -S (-4 6-0A1 <br />Inspectio Date: <br />t�f 4 C� <br />FA #: <br />D OD�� (1 <br />PR #: <br />--700 <br />Program Element: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum >_ 1320 gallons in tanks and containers over 55 gallons. <br />Complete one box for each tank or each cumulative container product type. <br />Pq/Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />- TA#: 5/ 6e 31:20 <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: $ O 0 O gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />� 0 <br />/ �� Product Type /J <br />Total Capacity: D O gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: z951X <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: ��A <br />/ <br />�� 6 L/ <br />Total Capacity: S -D O(j gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#:411 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: D 0 d gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />P Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: jam/ (,,7 <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />5 <br />Total Capacity: �.SD C) gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: 2- 5-0-0 gallons <br />Total Capacity for Site: gallons <br />Comments: <br />EHD Inspector: <br />Reviewed <br />By Initial: <br />Date:�- <br />Wo �. L.Dtt <br />Entered 1//) Date <br />By Initial: <br />EHD 28-01 <br />01/16/08 <br />