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U <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEI <br />600 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 />1V TerMf Pml PJ i /,U L Page of <br />Facility Address: ICity: I lnspe ion Date <br />Z`l�( N.4vL A� S�V&L46 i �� 11 <br />FA #: � � PR #:� � � � � ��� - -- Program Element: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum z 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#: r $Q <br />(>250 gallons) (>55 gallons and <250 gallons) � <br />1 (P3o1 000 & Product Type: J e <br />Total Capacity:gallons Install Date: <br />(per tank or cumulative for containers by product type) / <br />)4 Tank (2820) ❑ Containers (2821) #of Containers: TA#: B 159 l <br />(>250 gallons) (>55 gallons an <250 gallons) <br />2 (p 3 o O (0 O `{ 8 9' • �� Product Type: b' ese4, v* / S D ✓ <br />Total 6apacity:gallons <br />(per tank or cumulativMforcontainess by product type) Install Date: / �I <br />R Tank (2820) ❑ Containers (2821) #of Containers: TA#: C�E(j IORIZ ✓ <br />(>250 gallons)) (>5 gallons and <250 gallons) <br />3 (��0� b00[ygS�t Product Type: 25�� / 505 <br />Total Capacity: t gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />t. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6��193 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />4 113.944, O DU Product Type: �e e �Z,1— #33 03 <br />Total Capacity: allons % y <br />(per tank or cumulative fog containers by product type) Install Date: <br />) [ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />(>250 gallons) (>55 gallons and <250 gallons) t # <br />5 1, 3s(o) O0c Product Type: <br />Total Capacity: ga ons Install Date: <br />(per tank or cumulative o conta by o ct type) <br />Total Capacity this Page: gallons Total Capacity for Sit gallons <br />Comments: -4� (p (p 21 O O C) '140, S , 27 <br />01/16/08 <br />0 <br />Reviewedr.Entered Date: <br />By Initial, By Initial: <br />