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SAN JOAQUIN COUNTY <br /> ?NVIRONMENTAL HEALTH DEPARTMENT <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 /> 1S Y A V Page/of <br /> 016 r <br /> Facility Address: City: Inspectio Date: <br /> ws ),-/,t�v A My- c <br /> FA#: PR#: Program Element: <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#: 6 i9of <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: / fl PCO gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 0 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 15-1 L D <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: r 6( C? gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: B <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: Z P, 0 0 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> wank(2820) ❑ Containers (2821) #of Containers: TA#: -7 l <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,;Tank (2820) ❑ Containers (2821) #of Containers: TA#• / Q 3 <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: r C, � gallons Total Capacity for Site: 3 ® gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: AD � By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />