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C <br /> SAN JOAQUIN COUNTY <br /> :NVIRONMENTAL 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 Name: <br /> 5AIV /W L r A jN6 j►/Q Page of—L-- <br /> Facility Address: City: Inspection D te: <br /> o� v Mo <br /> FA#: PR#: Program Elem t: <br /> C7 ©a q��s' S/6 .7S Z <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 /> Tank (2820) ❑ Containers (2821) #of Containers: IT'A#: V <br /> (>250 gallons) (>55 gallons and<250 gallons) /f <br /> 1 Product Type: <br /> Total Capacity: a 0 6 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> L�YTank(2820) ❑ Containers (2821) #of Containers: #: Q ? ��— <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 0 Oe9 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> C1 Tank(2820) a-containers (2821) # -Containers: TAlk <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: 2 SO jallo(per tank or cumulative for containers by prod ) Install Date: <br /> ❑ Tank(2820) LXCont ' ers (2821) #of Containers: TA#: 5 to $ (� <br /> (>250 gallons) (>55 gall s and<250 gallons) <br /> 4 Product Type: 4l <br /> Total Capacity: d gallons <br /> (per tank or cumulative f containers by product type) Install Date: <br /> ❑ Tank 20) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 ga ns) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> T 1 Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> Z <br /> B 1 <br /> EHD Inspector: ` Reviewed j Date: EntereDa <br /> By Initial: <br /> 01.06 By Initial: O <br /> EHD 28-01 <br /> 01/16/08 <br />