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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 />G/ <br />—�US <br />6 � M A1� <br />Page of / <br />r <br />/ _ <br />Facility Address: <br />3 / <br />ASN s�r <br />City: <br />G Nva✓ <br />Inspection Date: <br />/o .3/0Y <br />FA FA #: 3 n 3 <br />PR #: <br />�25ag�,- T-( <br />Proe am Elefnent: <br />2-s3i <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) <br />El Containers (2821) <br />#of Containers: T <br />r9� ! <br />1 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: 10 C) () gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) <br />❑ Containers (2821) <br />#of Containers: TA#: 19 <br />2 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: <br />� G` 6 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) <br />FIC" ontainers (282 1) <br />#of Containe(s: <br />A#: A6—J, '7q�� <br />3 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />� <br />Product Type: � <br />Total Capacity: <br />f gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) <br />Yf Containers (282 1) <br />#of Contain s: J TA#: <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type. <br />Total Capacity: <br />gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />ffKf�L (2820) <br />❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />' <br />^" !• <br />Total Capacity: <br />� �� gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: <br />gallons <br />Total Capacity for Site: gallons <br />Commen <br />01 <br />K <br />COL�' <br />EHD Inspector: „ <br />.., <br />Reviewed Date: <br />By Initial: Q.l�-Q <br />Entered Date: <br />By Initial: / <br />EHD 28-01 <br />01/16/08 <br />