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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN'M <br /> 00 East Main Street,Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Nam e• _ <br /> UN J T g'q'V- 0), 1 Page of <br /> Facility Addri ss: t City: Inspecli Date: <br /> t o �o© r� ls T szo � 9 , <br /> FA#: PR#: Program Element <br /> 7 0 <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 /> T ink(2820) ❑ Containers (2821) #of Containers: TA#: ' <br /> (>25C gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: --416,7 7—d YeZ, O f <br /> Total Capacity: / 0 O d gallons Install Date: <br /> (per t nk or cumulative for containers by product type) ,, r <br /> (2820) ❑ Containers (2821) J #of Containers: TA#: 19TI—19o�l <br /> (>250,gallons) (>55 gallons and<250 gall <br /> 2 3g0 '0I Product Type: Y�A2 CJ L <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> F-1 Tank (2820) C`TContainers (2821) #of Containers:��� <br /> (>25( gallons) (>55 gallons and<250 gallons Type: �AQ <br /> 3 Product T e: <br /> Total Capacity: C II�allons I Install Date: <br /> (per or cumulative for conta producttype) - <br /> rCa�aci,,t�-., <br /> ontainers (2821) #of Containers: TA#: D I lo7a <br /> 4 (>55 gallons an O�Il3�s)4� �— U <br /> �Sy(�/ Rx % Y� Product Type: <br /> 1 <br /> gallons Install Date: <br /> e for containers by product type)an ( ❑ Containers (2821) #of Containers: TA#: <br /> (>25 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> To Capacity: gallons Install Date: <br /> (pecark or cumulative for containers by product type) <br /> otal Cap ity this Page: 17 S' gallons Total Capacity for Site: ` gallons <br /> dl,uunent� <br /> O� <br /> t <br /> r <br /> 119' pfwt3 <br /> EHD Inspector: Reviewed Date: / Entered Date: <br /> - By Initial: ( �Q.-r`� By Initial: b <br /> EHD 28-01 <br /> 01/t6/O8 <br />