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SAN JOAQUIN COUNTY <br /> - ENVIRONMENTAL HEALTH DEPARTMENT <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 NWIJ7--, <br /> - To x-row -role- <br /> Facility <br /> o2 Page of <br /> Facility Address: „ City: inspection D te: <br /> n a W okN�R S� �/g 10 $ <br /> FA#: O Z Z PR#:-jv/ Ll—3 � Program <br /> Y <br /> Tank/Container Information DD <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 /> EB/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1Product Type: <br /> Total Capacity: � 06 gallons <br /> (per tank or cumulative for containers by product type) Install Date: 2 /-i2 R(�Ai <br /> ❑ Tank (2820) L9 Containers (282 1) #of Containers: TA#: 7 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: p i G- <br /> Total Capacity: /3 ZD gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: 8 CA#: (� � <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: Q/[� <br /> Total Capacity: 4�f-© gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ElContainers (2821) #of Containers: TA#: a,,F1 70,5(e(p <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: �/i� r f,6 o r U <br /> Total Capacity: � D CD 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: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Z gallons Total Capacity for Site: Z gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: l Entered Date: <br /> • a By Initial: uj. 'UD By Initial: l� <br /> EHD 28-01 <br /> 01/16/08 <br />