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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN` <br /> o00 East Main Street, Stockton,CA 95202-302Y ` <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 /> -3-011 P� o A S Page / of <br /> Facility Address: City: Inspec io at � <br /> FA#: PR#: Program Element: <br /> O5a$o _ 24 <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#: 126-1 4P,53 7 <br /> (>250 gallons) (>55 gallons and<250 gallons) � r <br /> 1 Product Type: �/2 /"(�/^ <br /> Total Capacity: / pa0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) El Containers (2821) #of Containers: f TA# &5j- <br /> 2 <br /> gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: LICJ�/ <br /> Total Capacity: 2 d d gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) Containers (2821) #of Containers: 3 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: (/1/X TA- 9/ <br /> Total Capacity: ` 6,5 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) V/60'ntainers (2821) #of Containers: 3 TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) G say <br /> 4 � Product Type: LlS%�� <br /> Total Capacity: l J gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 2 Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) �{ 55 gallons and<250 gallons) <br /> 5 0 � Product Type: <br /> Total Capacity: -7,149 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 3 S S d gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: /� Reviewed Date: Entered Date: <br /> (� By Initial (���� 0'(0-09 By Initial: <br /> EHD 28-01 V <br /> 01/16/08 <br />