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SAN JOAQUIN COUNTY <br />3NVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <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 />(I—� <br />/ / / r_- A2 /V �, C4--- <br />_V / <br />Page 'r✓ o f V <br />Facility <br />Facility Address: <br />City: <br />Inspect' <br />n Da e• <br />Z J/ A!/, <br />S��CIII <br />n <br />FA #: <br />PR #: <br />Program Element: <br />-37 <br />a l <br />g3 <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum ;2:1320 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) <br />#of Containers: TA#: <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Q V <br />Total Capacity: '5 b rr <br />0 gallons <br />Install Date: <br />n �+ J <br />(� ei✓1 U2b <br />(per tank or cumulative for containers by product type) <br />P�ZTank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 19 6/ 253 <br />Z <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />/ J <br />Total Capacity: 4 gallons <br />Install Date: <br />('� M <br />N(per <br />tank or cumulative for containers by product type) <br />❑ Tank (2820) lid" Containers (2821) <br />#of Containers: 2-- TAM <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />r <br />Type: D / d <br />J/Product <br />Total Capacity: � gallons <br />Date: <br />U; <br />(per tank or cumulative for containers by product type) <br />Install <br />❑ Tank (2820) Containers (2821) <br />#of Containers: TA#: <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: kZA S T -//- <br />Total Capacity: 2- Zr% gallons <br />Total <br />Install Date: <br />, 1 <br />(�,+� t�4 <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) U?6ontainers (2821) <br />#of Containers: S TA#: <br />0'2$ <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />J <br />Product Type: /1-7 o -7'd (` ./L <br />Total Capacity: Z 7,F_ gallons <br />Install Date: <br />C`e C✓'V <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: g <br />gallons <br />Total Capacity for Site: <br />gallons <br />Comments: <br />HD Inspector: <br />Reviewed Date: <br />Entereddate: <br />C • �S ♦ <br />By Initial: <br />By Initial: <br />I <br />EHD 28-01 <br />01/16/08 <br />