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_ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-36-, <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 1� k C_ Page of <br /> Facility Addres City: Inspec•on te: <br /> ZOL- <br /> FA#: PR#: Program Element: <br /> oma? 2123 <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: TA#: Q-5'172 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: (>Se/� <br /> Total Capacity: 2 1� gallons <br /> (per tank or cumulative for containers by product type) Insta <br /> (2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: l�� 6i Z ( -7''��vl(, rl-vpT <br /> Total Capacity: �i�o gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ElContainers (2821) #of Containers: TA#: 4±-L,2,0 02 <br /> (>250 gallons) (>55 gallons and<250 gallons) p <br /> 3 Product Type: (,(S'�� O/ <br /> Total Capacity: 0 O 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: �t <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) fXContainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) � <br /> 5Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> d <br /> Total Capacity this Page: SQ - A6 0565 gallons Total Capacity for Site. gallons <br /> Comments: <br /> EH Spector: Reviewed Date: Entered Date: <br /> By Initial: TBy <br /> Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />