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SAN JOAQUIN COUNTY <br /> +� ENVIRONMENTAL HEALTH DEPARTMEI <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 /> L / AlS c> Page of <br /> Facility Address: City: Inspect' n D te: <br /> 13LA C/KD1#qM0rJ0 WA / <br /> FA#: PR#: Program Element: <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#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: Z J`U gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: Qsl(ems? <br /> 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) Product Type: '�r ii2 <br /> /� ��� <br /> Total Capacity: Z� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> P Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 O �� Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> (-Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: /'LIDO <br /> Total Capacity: 160 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> �ank (2820) ontainers (2821) #of Containers: _ TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) l <br /> 5 Product Type: zOo <br /> Total Capacity: 'Z" gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 2 0 O gallons Total Capacity for Site: s 2 Q gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: / <br /> EHD 28-01 <br /> 01/16/08 <br />