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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEl <br />600 East Main Street, Stockton, CA 95202-30z9 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 1f1eb:,%v-ww,sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />0 <br />Iqo/ <br />02 <br />70/ <br />.EHD 28-01- <br />01/16/08 <br />Facility Name: <br />p,4/ (� b <br />Page of <br />IL s2r �� <br />, <br />Facility Address: <br />(� ► V � l.� pl <br />City: <br />\ � V S� ! Vim/ <br />c l <br />Inspecti Date: <br />� �/� <br />FA #: <br />�1� <br />PR #: <br />0�2 �- <br />Program Element: <br />2 <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 />[ Tank (2820) ❑ Containers (2821) #of Containers: TAM <br />1 <br />` (> 50 gallons) (>55 gallons and <250 gallons) NI LYS 1 # <br />I , 006" coo Product Type: rJ�--N" <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: 9 <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />/)008,,000 Product Type: c�t-1 ur 2 <br />Total Capacity. gallons - <br />Install Date: <br />(per tank or cumulative fof containers by product type) <br />Tank 2820 ❑ Containers 2821 <br />( ) ( ) #of Containers: TA#: X51 za7 <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />/, ,3 Ste, O DC7 Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative f r containers by pr duct type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: &19`'j/ <br />4 <br />(>250 gallons) (>55 gallons and X250 gallons) <br />CO aC)o o 0 Product Type: y () to e44 4 C,-;>/ <br />C <br />Total Capacity: gallons <br />for <br />Install Date: �9LP 9 <br />(per tank or cumulative containers by product type) <br />tg Tank (2820) ❑ Containers (2821) #of Containers: TAM <br />(>250 gallons) (>55 gallons and <250 gallons) <br />5 <br />2 q'4 000 <br />&l <br />Product Type: — <br />Total acity. gallons <br />Install Date: CL --j L' `? ` 0 rS <br />iners product type) <br />(per tank or cumulativmztz <br />�—- <br />Total Capacity this Page: <br />gallons <br />Total Capacity for Site: - gallons <br />Comments: 2 O O <br />CD 2 <br />EHDIns <br />Reviewed Date <br />By Initial:4 <br />Entered Date: <br />By Initial: <br />0 <br />Iqo/ <br />02 <br />70/ <br />.EHD 28-01- <br />01/16/08 <br />