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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN-, <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 /> l- ZZ- C. rpRin <br /> Page Of <br /> Facility Address: 99 City: inspectio Date,: ` <br /> FA#: PR#: Program Elemi <br /> FA00 135)f R ?-3 9 <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 /> m Tete one box for each tank or each cumulative container product e. <br /> ak (2820)nContainers (2821) #of Containers: . TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) n <br /> 1 Product Type: � z� <br /> Total Capacity: Z-C;' D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) D Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: C 1,'/3 0,4 <br /> Total Capacity: �' Z UD gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> E!r Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) ''/� 0` J <br /> 3 Product Type: [/� [/ <br /> Total Capacity: 44 Z"06 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 /> 4 Product Type: <br /> Total Capacity: 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: b gallons Fotal Capacity for Site: 8 c7 o gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: / Entered Date: <br /> By Initial: vv v �1 1 _Un/U By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />