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SAN JOAQUIN COUNTY <br /> y, ENVIRONMENTAL HEALTH DEPARTMEN <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 N : /r / <br /> Iq R I�. J ®�!� .5- L- L— Page of <br /> Facility Address: <br /> City: Inspec777 <br /> e: <br /> '2. ! 3 C" nqA v0 <br /> FA#: PR#: Program Element: <br /> 19 1g -z' 0 <br /> Tank/Container Information <br /> Complete r 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 /> WI/Tank (2820) ❑ Containers (2821) #of Containers: TA#: / 7 T (� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: S ® gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 7Z TT <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2Product Type: i <br /> Total Capacity: �a A gallons - <br /> (per tank or cumulative for containers by product type) Install Date: <br /> E?Tank(2820) ❑ Containers (2821) #of Containers: TA#: �J7 <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 3 Product Type: �!��2,.c,P�� <br /> Total Capacity: j--a d gallons <br /> (per tank or cumulative for containers by product type) Install Date: _ <br /> ank 2820 ❑ Containers 2821 <br /> ( ) ( ) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: � � .S <br /> Total Capacity: 0 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Ze/Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: /G 0 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date' - __-- _--- <br /> Total Capacity this Page: gallons Total Capacity for Site: O gallons <br /> Comments: <br /> EHD Inspector: ti /' Reviewed Ddtc: Entered D te: <br /> f) By Initial: rj-tf\ By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />