Laserfiche WebLink
JAN JOAQUIN COUNTY <br />?NVIRONMENTAL HEALTH DEPARTMENT <br />000 East Main Street, Stockton, CA 95202-302 <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 />Page __�_ of> <br />Facility Address: <br />' <br />�� W <br />City, Q � <br />,+ �, <br />z <br />InspF q <br />�� 6 Py <br />FA #: <br />00037R4 <br />PR #: <br />t965C2-g12-110 <br />Progra Elet: <br />�3 <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons <br />in tanks and containers over 55 gallons. <br />Complete one box for each tank or each cumulative container product type. <br />�ank (2820) <br />❑ Containers (2821) <br />#of Containers: <br />TA#: z Z le'? 7 f <br />1 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) i <br />Total Capacity: <br />0, ce ; <br />gallons <br />Product Type: /2„� <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />C -Tank (2820) <br />❑ Containers (2821) <br />#of Containers: <br />TA#: "- <br />2 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />j r,,, : <br />Product Type: .� <br />Total Capacity: <br />a gallons <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 />3i <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Total Capacity: <br />/ galions <br />Product Type: <br />(per tank or cumulati <br />or containers by product type) <br />Install Date: <br />G?"*Tank (2820) <br />❑ Containers (2821) <br />#of Containers: <br />TA#: I, :z <br />4 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: p +< <br />Total Capacity: <br />so o gallons <br />(per tank or cumulative for containers b <br />(p y product type) <br />Install Date: <br />E?"Tank (2820) <br />❑ Containers (2821) <br />#of Containers: <br />TAM <br />5 <br />(>250 gallons) <br />Total Capacity: <br />(>55 gallons and <250 gallons)) <br />Sm <br />a <br />Product Type: <br />gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: <br />�J ; �" gallons <br />Total Ca aci for Site: / p '� gallons <br />P ty ��6a - 1�(r <br />Comments: <br />,4. V <br />EHD Inspect oyy <br />(� <br />Reviewed <br />By Initial:-1-kt,� <br />Date: <br />Entered Date: <br />By Initial: <br />EHD 28-01 1 o . l cj - 10 / ' <br />01/16/08 <br />