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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> "600 East Main Street,Stockton,CA 95202-3027' <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: Page Of <br /> /- UoqI: ,554V) <br /> Facility Address:63 ® ® F.0City; Date:Inspectioggq <br /> e 77&/O <br /> 0 <br /> FA#: kH#: Program Element: <br /> 213 / <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> ank (2820) ❑ Containers (2821) #of Containers: TA#: 0 n <br /> (>250 gallons) (>55 gallons and Q50 gallons) I <br /> Product Type: .__r� <br /> 1 ly XI <br /> Total Capacity: LD O gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> C]'fFank(2820) ❑ Containers (2821) #of Containers: TA#: IR <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 2 Product Typ ' <br /> Total Capacity: ZSa gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ]'Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 3 Product Type: o / �J <br /> Total Capacity: Z SO gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 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: 0 gallons Total Capacity for Site: gallons <br /> Comments: 'V7./ L <br /> 15 <br /> i e f2&0 stiz. <br /> IN �aNS . <br /> IL <br /> EHD Inspector: Reviewed Date: Entered Dat . <br /> ��[/;`� r/t, I By Initial: / _2♦Og By Initial: �J <br /> EHD 28-01 ku V'` '4I Cut'- eF I" I i( l7 <br /> 01/16/08 c.. t2a t <br />