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` SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN7 <br /> A0 East Main Street,Stockton,CA 95202-302> <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name:CpASo ,f n `/ / r� Page ) of <br /> lll7Kry (, <br /> Facility Address: qty: Inspect' n Date: <br /> AV70 �� cid. '"Al <br /> FA#: ) / PR#: Pra>'r <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 /> Com Tete one box for each tank or each cumulative container product type. <br /> ❑ Tank (2820) Containers (2821) #of Containers: 7- TA#: 4!,6j- !p 8 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: D� l✓ <br /> Total Capacity: //0 gallons <br /> (p tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: D51&S(2 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: 0/ 6 <br /> Total Capacity: 5-7-2- gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Eg/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: 1414�� !�� <br /> Total Capacity: S 9 Z gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> U Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 S� Product Type: 1jJ/R,1f�C d/ L <br /> Total Capacity: 3 gallons <br /> (per tank or cumulative for container-' product type) Install Date: <br /> 9 <br /> ❑ Tank (2820) _ntainers (2821) #of Containers: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type _ <br /> Total Capacity: _ SJ gallons ` <br /> (per tank or cumulative for conby product type) Install Date: <br /> Total Capacity this Page: 7 + gallons Total Capacity for Site: s 9 gallons <br /> Comments: f <br /> EHD Inspector: _ Reviewed Date: ,/ Entered DEtLe <br /> By Initial: � 8-x{-0`6 By Initial: <br /> EHD 28-01 el <br /> 01/16/08 <br />