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SAN JOAQUIN COUNTY <br />i ENVIRONMENTAL HEALTH DEPARTMEN7 <br />600 East Main Street, Stockton, CA 95202-3025 <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 />r1jc LLE A n��K G n t-. )qIv <br />Page � of � <br />Facility Address: City: <br />'2'7// 17 <br />Inspectio Date: <br />V <br />FA #: <br />PR #: <br />Program Element: <br />37 9 <br />t5'42'g <br />v; <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 />l9 Tank 2820 ❑ Containers 2821 <br />( ) ( ) #of Containers: TA#: L95 �. <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) � <br />Product Type: f2e ib r)e1000--j <br />Total Capacity: ,,v d gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type:.4y 'F7 Ace,, L> <br />Total Capacity: SQF) gallons i'— <br />L� <br />(per tank or cumulative for containers by product type) Install Date: <br />Er'Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: tv A T'9D / � <br />��'r <br />Total Capacity: 2-66 gallons <br />Install Date: <br />(pr tank or cumulative for containers by product type) <br />P1erTank (2820) ❑ Containers (2821) #of Containers: TA#: 02 <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: iWdJ 1 <br />Total Capacity: Z ,So gallons f <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />R"Tank (2820) ❑ Containers (2821) #of Containers: TA#: o 49 <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />� � Product Type: /�,�l�jE�R <br />Total Capacity: gallons pem o <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: gallons <br />Total Capacity for Site: p gallons <br />Comments: <br />D IV <br />�T 1 f 1 �i✓�� / Z <br />EHD Inspector: <br />C , Q� <br />Reviewed Date: <br />By Initial: `, O1 b_0� <br />Entered Date: / <br />By Initial: / Q <br />EHD 28-01 <br />01/16/08 <br />(0 <br />,1Vk, <br />