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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN" <br /> 600 East Main Street,Stockton,CA 95202-31 <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 /> E161-CA /&Xvp-,yPage-/—of <br /> Facility Address: City: InsY- -T—:;-a�'- <br /> ection Date- <br /> S-5,5 Al- /�/n/ S7' M�9„��-/ <br /> FA#: PR#: Program Element: <br /> �a(o k 1 1aS -2831 <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 /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: oelg <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: gallons <br /> (Per tank or cumulative for containers by product type) Install Date: <br /> EiiZTank(2820) ►,t,ontainers (2821) #of Containers: TA#: <br /> 6-11�8q� <br /> (>250 gallons) (>55 gallons and 450 gallons) <br /> 2 1/4 / Product Type: Q .� C�7F� <br /> Total Capacity: -2,-,7-� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> EWITank (2820) stainers (2821) #of ContainErb: TA#: ��gl <br /> (>250 gallons) (>55 allons and<250 gallons) <br /> 3 �y �' Product Type: <br /> Total Capacity: 2=_- gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> -- <br /> El Tank (2820) -Containers (2821) #of Containers: - TA#: .Sl <br /> (>250 gallons) (>55 gallons and 450 gallons) __- <br /> 4 �._ - Product Type: �G�n, LG P <br /> Total Capacit-- Sv gallons <br /> (per emulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TAM f),�S-/ og <br /> (>250 gallons) (>55 gallons and 450 gallons) <br /> 5 ' / ! Product Type: ,,�J O/ <br /> Total Capacity: <br /> /-00 _gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: - S'' gallons Total Capacity for Site: 2_ -� j cy` gallons <br /> Comments: iLjVT <br /> 1 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> EHD 28-01 V� <br /> 01/16/08 <br />