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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEP ARTME' <br /> 600 East Main Street,Stockton,CA 95202-30 9 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Na�m+e: O/ L G f A N f 11 <br /> J : r Q r-- G= 4� rf/N V r Page / of l/ <br /> Facility Address: City: Inspc No Date• <br /> Z jF LOV J S& /aVF /�n/ Tt-e A F 0 g <br /> FA#: PR#: Program', <br /> rogram Element- <br /> 0010091 1 9/YFV s3i <br /> Tank/Container Information <br /> Complete for all sites with cu ative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Co Tete one box for each tank or each cumulative container product type. <br /> t1fkftk(2820) EVContainers (2821) #tof Containers: _� TA#: jO ,�5 j&17Y <br /> 50 gallons) (>55 gallons and<250 gallons) -- <br /> 1 Product Type: � (/ <br /> Total Capacity: 17-19 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ank (2820) ontainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: r"'lelq "*V1 <br /> Total Capacity: 2-�D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Bank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: Of li <br /> Total Capacity: r6/q gallons <br /> --(per tank or cumulative for containers by product type) Install Date: <br /> UX"1'ank (2820) ❑ Containers (2821) #of Containers: TA#: 0,1714 1 7 7 <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 4 /` Product Type: <br /> Total Capacity: b9� gallons Install Date: <br /> ( er tank or cumulative for containers by product type) <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: _ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: Ql <br /> Total Capacity: / 6 6 O gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page:'Z gallons Total Capacity for Site: 'Z'? gallons <br /> Comments: <br /> EHD Inspector: Reviewed / te: Entered Date: <br /> By Initial: S a By Initial: <br /> EHD 28-01 <br /> 0l/16/08 <br />