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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEP. <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 Na e: <br /> J e, 9 Page of <br /> Facility Address: L City: Inspectionate: <br /> 13 <br /> 10 a �- / 7,12-1 L <br /> FA#: PR#: t Program Element: <br /> 2� 05a a <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> IP/Tank(2820) ❑ Containers (2821) #of Containers: TA#: 'J 74' t <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: (,-/a Y <br /> Total Capacity: .700 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: 119671-7 &1'e 0 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 S- 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: TA#:ri Lo <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> � 3 � � �® Product Type: (fes <br /> i Total Capacity: 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: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> d <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: , b d D gallons Total Capacity for Site: gallons <br /> Comments: 3 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> C - By Initial: kA -y By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />