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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME1 <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 /> // ! - 1 <br /> A L J76wl5 LL Tl (JGkirD— C 0 Page of / <br /> Facility Address: City: Inspec�iyn_ �1�te_ <br /> 2 T vfz s GA Go 6���j/ 8 <br /> FA#: PR#: Program Element: <br /> ao S-2 641- -2,S <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 O G Product Type: 0A�L <br /> Total Capacity: / C) gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> L�rtank (2820) ❑ Containers (2821) #of Containers: TA#: eq-5110 �33� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 20 0 Product Type: <br /> Total Capacity: � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 1U,Tank(2820) ❑ Containers (2821) #of Containers: TAM '0 6j- le 3 C3(P <br /> (>250 gallons) (>55 gallons and<250 gallons) Q (� <br /> 3 Product Type: /�V <br /> Total Capacity: 5 SCJ gallons <br /> (per tank cumulative for containers by product type) Install Date: <br /> ank(2820) (containers (2821) #of Containers: TA#: <br /> 50 gallons) �S'55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: ZSO gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ank (2820) Containers (2821) #of Containers: y TA#: 5 � <br /> 50 gallons) (>5 gallons and<250 gallons) <br /> 5 IAPProduct Type: O fTotal Capacity: gallons <br /> (per tank or cumulative for ontainers by product type) Install Date: <br /> Total Capacity this Page: Z3 3ot7 gallons Total Capacity for Site: 23 3 0 gallons <br /> Comments: <br /> w o 95'c 4(_0rJ A Z_J Ar N <br /> EHD Inspector: Reviewed Date: Entered / Date- <br /> By Initial: � �.y.� By Initial: V // <br /> EHD 28-01 l� V <br /> 01/16/08 <br />