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SAN JOAQUIN COUNTY <br />W."v <br />NIRONMENTAL HEALTH DEPARTM <br />0 East Main Street, Stockton, CA 95202- 2 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name: n 5 C <br />4r\ <br /># a � <br />Page / of <br />Facility Address: <br />HU-, ?9 <br />City: <br />S%lG <br />InspectiIn D te: <br />7��0 <br />FA #: <br />000 6 <br />PR #: <br />1J�z- <br />6 Z 0 <br />Program Element: <br />2:- <br />Tank/Container <br />Tank/Container Information <br />Complete for all sites with <br />cumulative aboveground storage of petroleum > 1320 gallons <br />in tanks and containers over 55 gallons. <br />Complete one box for each tank or each cumulative container product type. <br />T<Tank (2820) <br />❑ Containers (2821) <br />#of Containers: <br />TA#: <br />1 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: 4!!�—.4 <br />Total Capacity: <br />r o ° gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Ld' Tank (2820) <br />❑ Containers (2821) <br />#of Containers: <br />TA#: <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />2 <br />Total Capacity: <br />.S o � gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) <br />['Containers (2821) <br />#of Containers: <br />TA#: <br />3 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: r -'L-2 o <br />?OR UJ <br />Total Capacity: <br />Z Z 0 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) <br />a ontainers (2821) <br />#of Containers: <br />TA#: - <br />4 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: <br />Z 2, 7) gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />i <br />El Tank (2820) <br />Containers (282 1) <br />#of Containers:y <br />1 � <br />TA#: l2�` • <br />5 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: � <br />(i <br />Total Capacity:O <br />gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: <br />�,S�iJ <br />gallons <br />TTotal Capacity for Site: / DS gallons <br />Comments: <br />EHD Inspector: <br />C. <br />Reviewed Date:Entered <br />By Initial: <br />Date: <br />By Initial: <br />EHD 28-01 <br />01/16/08 <br />