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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENT <br /> 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 /> Page©�� Page__'L_of <br /> Facility Address: '4City: Inspecti Date: <br /> '-`'1 ,E4� may✓ 7"114 <br /> FA#: PR#: Pr am Ele ent <br /> © oa5"i�o :Z� �3 7 <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) ❑ Containers (2821) #of Containers: TA#: V(e$'$$ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: d—A S 17 <br /> Total Capacity: /C?C24 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: ®j 1&5"V <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: 0 <br /> Total Capacity: `7 O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> UKTank (2820) ❑ Containers (2821) #of Containers: TA#: • l� <br /> (>250 gallons) (>55 gallons and<250 gallons) ^/ <br /> 3 Product Typek- y(�&,STI_A.� <br /> Total Capacity: 3 d CF gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) elcontainers (2821) #of Containers: Y TA#: i9j(gyp <br /> (>250 gallons) (>55 gallons and<250 gallons) // <br /> 4 Product Type: 016- <br /> Total Capacity: z�a 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<250 gallons) <br /> 5 Product Type: a l <br /> Total Capacity: gallons <br /> (per tank or cumulative fo containers by product type) Install Date: <br /> • <br /> Total Capacity this Page: Z Q gallons Total Capacity for Site: 21 gallons <br /> Comments: <br /> 1 ocw ,qt-(-DN X'AS -fiq C <br /> 0 Fk <br /> S <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> r By Initial: W ti 1,�t.� By Initial: Q ¢ <br /> EHD 28-01 t/ <br /> 01/16/08 <br />