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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPART <br /> M <br /> 0 East Main Street, Stockton,CA 95202- <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility N e: <br /> V C- //v C/ Page of <br /> Facility Address: City: Inspect: D e: <br /> �3 sfi o9 <br /> FA#: PR#: Program Element: <br /> a o0 9ZS��- SZ 3 2--2, 3- '?3 -;;�- <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: I TA#: Za&qq9/ <br /> (>250 gallons) (>55 gallons and<250 gallons) Ir <br /> 1 Product Type: 0 / <br /> Total Capacity: •S &10 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 10 all <br /> ❑ Tank (2820) UP/60ntainers (2821) #of Containers: Z TA#: 4 <br /> (>250 gallons) (>55 gallons and<250 gallons) yA lY� <br /> 2 Product Type: '7 �' I <br /> Total Capacity: f/ P gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) P1 ontainers (2821) #of Containers: _ TA#: �Z <br /> (>250 gallons) (>55 gallons and<250 gallons) 9-4-C <br /> 3 Product Type: <br /> Total Capacity: ;!rr gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) f <br /> 4 �dd 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#: / LO IA6 <br /> (>250 gallons) (>55 gallons and<250 gallons) I <br /> 5 O� Product Type: d <br /> Total Capacity: /D d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons FTotal Capacity for Site: gallons <br /> Comments: <br /> old <br /> 42' <br /> 3x <br /> EHD Inspector: ` Reviewed Date: Entered Date' <br /> (/JL By Initial: Wj By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />