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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT 1 <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 Na 5; <br />I1 y ON S MA/IV T <br />cNnt✓G& o �RATI61VS <br />I <br />Page �of <br />Facility Address: <br />0� 1�• �'/N� ST <br />City: f r I <br />0 <br />R, w <br />Inspecti n Date: <br />2 cls <br />FA #: <br />0016613 <br />PR #: <br />o5aga�� <br />Program Elemen : <br />2�3y <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground <br />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 />Fr'TTank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />Q' <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />� <br />Product Type: �� S <br />Total Capacity: L o ® gallons <br />Install Date: <br />(per tank r cumulative for containers by product type) <br />C?ZTank(2820) ❑ Containers (2821) <br />#of Containers: TA #: c96-1 Le' <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: /6 (7 O 9 gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />-77 <br />Total Capacity this Page: <br />gallons <br />FTotai Capacity for Site: <br />O 6 gallons <br />Comments: AIA; A/ OR a n/ <br />EHD Inspector: <br />+ too <br />Reviewed Date: "� <br />By Initial: � I _"-0 <br />Entered <br />By Initial: <br />Date: <br />`( <br />EHD 28-01 <br />01/16/08 <br />