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SAN JOAQUIN COUNTY <br />' ENVIRONMENTAL HEALTH DEPARTM <br />600 East Main Street, Stockton, CA 95202-3W_y <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 />S C #a�- l/iiiQSrli �/21C�1� <br />Page / of <br />Facility City: Address: <br />3 3 Hwy ?9 sfifc <br />Inspecti n D te: U 3 <br />� <br />FA #: <br />D D o (/67 <br />PR #: <br />_Z_ 620 <br />Program Ele <br />gyr <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 />HT"Tlank (2820) ❑ Containers (2821) #of Containers: TA#: <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />PFT,duc <br />ype: <br />Total C '-ty:. gallons <br />Install Date: <br />or cumulative for containers by product type) <br />�(pe�tank <br />10 Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />2 <br />(>250 gallons) (>55 gallons and fL50 gallons) <br />Prod <br />d <br />Total Capacity: S <br />Install T_'ate: <br />er ive or containers by product type) <br />ank (2820) Containers (2821) #of Containers: <br />3_-----Pro <br />(>250 gallons) >5 gallons and <250 gallons) ----- <br />uc�e: ?02 ov <br />Total Capaci=- gallons <br />Install Date: <br />_(per-ta or for containers by product type) <br />❑ Tank (2820) UAContainers (2821) #of Containers: TA_ #: __- - ____.-- <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />-Produc�_rsipe: a <br />Total Capacit gallons <br />Install Date: <br />(per-tani r cumulative for containers by product type) <br />l <br />El Tank (2820) Containers (2821) #of Containers: � TA# �e (Q�. <br />(>250 (>55 gallons and <250 gallons) <br />5 <br />gallons) <br />Product Type: U <br />Total Capacity: J/b gallons <br />{iikpertaor cumulative for containers by product type) Install Date: <br />Total Capacity this Page: gallons <br />I Total Capacity for Site: �� gallons <br />Comments: l <br />Ck '5 IW/ D 16l/J , <br />EHD Inspector: Reviewed Date: <br />Initial: j I "�� <br />Entered Date. <br />By Initial: ' <br />EHD 28-01 <br />01/16/08 <br />P0, <br />�\��,,� <br />