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SAN JOAQUIN COUNTY 10 <br /> ENVIRONMENTAL 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 /> T 1 CI NCERY ) �O L/Q ALAS T Page of <br /> Facility Addfess: City: Inspectn Date: <br /> 30?()3 ACAq r Z S <br /> FA#: PR#: P66ram a ent: <br /> 000 6405 1 3156sz I 2 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 /> Complete one box for each tank or each cumulative container product type. <br /> 19'Tank (2820) ❑ Containers (2821) #of Containers: TA#: S((,Q [' <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: /0 00 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TAM 5I&OL <br /> (>250 gallons) (>55 gallons and<250 gallons) S <br /> 2 Product Type: <br /> Total Capacity: Z- Sr gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> IP/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0, <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: lbagL ,,2-�-� <br /> Total Capacity: ZUd� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: D51(o 0 [Q 3 <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 /> ❑ Tank(2820 ontainers (282 1) #of Containers: TAA. <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: gallons FTotal Capacity for Site: /Z -3 o S— gallons <br /> Comments: '�� O <br /> EHD Inspector: Reviewed ` Date Entered Date: <br /> By Initial: �( 2 (� By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />