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t SAN JOAQUIN COUNTY <br /> 'NVIRONMEN'TAL HEALTH DEPARTMENT <br /> ! .r ra t . <br /> 0 East Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax {209)468-3433 Web:wwwsjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> FacilityFNh ^ D �, Page of <br /> City: inspection at <br /> Facility Add/re/ss: t R W �� Q G <br /> 3 T" Program El <br /> Le <br /> FA#: <br /> 001 60 . ' <br /> ,} <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 /> �� <br /> ❑ Tank(2820) Containers (2821) .#of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 1 Product Type: <br /> Total Capacity: 'Z�r� gallons Install Date:. <br /> (per tank or cumulative for containers by product type) <br /> Tank (2820) ❑ Containers (2821) #of Container's: !!TA#: <br /> L <br />'t (>250 gallons) (>55 gallons and X250 gallons) <br /> 2 tt :, Product Type: O G <br /> Total Capacity: ` " D gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> alikl(2820) ❑ Containers(2821) #of Containers: TA#: <br />' (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: e� gallons k * <br /> (per tank or cumulative for containers by product type) , Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) ' #6fContainer's: TA#:' ~ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons §. <br /> (per tank or cumulative for containers by product type) Install Date: <br /> i1, f <br /> ❑ Tar&(2820) ❑ Containers (2821) Wof Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) ' .. <br /> 5 Product Type: <br /> w. <br /> Total Capacity: gallons f <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 1, - <br /> Total Capacity this Page: gallons Total Capacity for Site: ! 47 gallons <br /> Comments: <br /> i <br /> l ze �p 11 ri✓ fi , <br /> 'i <br /> V <br /> I 3, <br /> l . <br /> i <br /> r EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: !x D <br /> EHD 28-0i <br /> 01/16/08 <br /> f <br />