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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 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: <br /> rCA /Mowyp- Page-/—of <br /> Facility Address: City: Inspection Date- <br /> S-_5"5 /►/. AWAI ILIA Tr f `J''06P <br /> FA#: PR#: Program Element: <br /> 00 (0 8 d a � -Z83 / <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#: O51 o rl <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 /> E41"T'ank(2820) h t—ontainers (282 1) #of Containers. TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 ,� Product Type: <br /> Total Capacity: �.7 � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) 1r itainers (2821) #of ContaineLs: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: Z 7 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: / TA#: 29,6-1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4Product Type: �,Cb� <br /> Total Capacity: s jv gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> EjY/Tank(2820) ❑ Containers (2821) #of Containers: TA#: ��/ <br /> (>250 gallons) (>55 gallons and<250 gallons) L. <br /> 5 © Product Type: �� �'�� Q/ <br /> Total Capacity: . / 0 d _gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Z. 0 gallons Total Capacity for Site: 2 O gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: K, Entered Date: <br /> By Initial: �•b vD By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />