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SAN JOAQUIN COUNTY <br /> iNIVIRONMENTAL HEALTH DEPARTMEN' <br /> x600 East Main Street,Stockton,CA 95202-3027`` <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> No r✓ r/2 A d d -7-11 7J D Page L of_,/ <br /> Facility Address: f�`y�,, <br /> J Y � [napecgpn Fate: <br /> FA#: Z31 <br /> PR#: J( - <br /> Program Element: <br /> CEElemeeent: O <br /> o d d O a8 z 8 "✓ <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 /> Tank (2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 1 Product Type: 0-t��pQ/ <br /> Total Capacity: / O 0 b0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) E Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<50 gallons) - <br /> 2 -n -- L/C, <br /> Total Capacity: gall <br /> (per tank or cumulative for containers by product typt <br /> Q Tank(2820) ❑ Containers (2820 � j TA#: <br /> (>250 gallons) (>55 gallons and<250 galloi <br /> 3 �v <br /> Total Capacity: o'd gallon <br /> (per tank or cumulative finers by product type) <br /> an (2820) ❑ Containers (2821) #of Containers: TA#: _ r 0 <br /> 4 <br /> (>250 gallons) (>55 gallons and<50 gallons) Product T yp e: A//95725C9! <br /> Total Capaci � U D gallons <br /> (pker{noun <br /> e,talive for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <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: 8 gallons Total Capacity for Site: 6 CYST gallons <br /> Comments: <br /> dA 12,01 t M /� <br /> Ceti fL- (b II ) <br /> EHD Inspector d Reviewed Date: Entered Date: <br /> By Initial: �.G�•O% By Initial <br /> EHD 28-01 <br /> 01/16/08 <br />