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SAN JOAQUIN COUNTY <br /> 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 Nam/► Z' r v T Pagey of 2 <br /> Facility Address: City Inspection Dat <br /> FA#: VPR#: Program Ele7ent: <br /> 3 1 A5079 5 -z-g 3 <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 /> Compjete one box for each tank or each cumulative container product type. <br /> ❑ Tank (2820) Containers (2821) #of Containers: -7/ TA#: B,617-3& f1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: /2d 1"PE A L (21 <br /> Total Capacity: 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) V/60'ntainers (282 1) #of Containers: "Y TA#: <br /> (>250 gallons) (>SS.gallons and<250 gallons) � <br /> 2 Product Type: �/1 Czo .•On v!(/ <br /> Total Capacity: D gallons <br /> (per tank or cumulative for co tainers by product type) Install Date- <br /> El Tank <br /> ate:ElTank(2820) C;Containers (2821) #of Containers: y TA#: '4 Aje l <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: 116 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (282 1) #of Containers: Y TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: CZ-,,oW1j fL 47-24,0,5� <br /> Total Capacity: 1/ 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: 7) <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: S%,✓7WO-7"-1 G AZZ� <br /> Total Capacity: //D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: k!r <br /> (y <br /> EHD 28-01 <br /> 01/16/08 <br />