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SAN JOAQUIN COUNTY <br />,NVIRONMENTAL HEALTH DEPARTMENT <br />WO 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 />L ti /�T�/�,//i Z-� � G G l✓!NO-' �� G <br />Page f of <br />T <br />Facility Address: City: <br />12 �'v �0 ,r Z3 sT�- �SZo.r <br />Inspection ate: <br />/yay <br />FA #: <br />61 <br />PR #: Program Eleme t: <br />- <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 />Y "1 ank (2820) ❑ Containers (2821) #of Containers: TA#: 05-1 733le <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: 14/A Ka b/ �%% <br />// <br />Total Capacity: 44,9 0 ,!5 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0,j j 71, 3 <br />2 <br />(>250 gallons) (>55 gallons and Q50 gallons) <br />Product Type: %/� <br />`I� os <br />Total Capacity: I%9 `/—gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Eg/Tank (2820) ❑ Containers (2821) #of Containers: TA#: l ✓% 338, <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity:lj b d gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Ed,lfank (2820) ❑ Containers (2821) #of Containers: TA#: t 6—) 7 <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) / <br />Product Type: / !/R' 1� 11VE D / (/ <br />Total Capacity: d & e gallons <br />-� <br />(per tank or cumulative for containers by product type) Install Date: <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) � <br />Product Type: Cg' �vs <br />Total Capacity: jf b gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: I� gallons <br />Total Capacity for Site: �'Z g gallons <br />Comments: <br />AL <br />EHD Inspector: C _ <br />Reviewed Date: <br />By Initial: o1_kj. a� <br />Entered Date: /y <br />By Initial: `Z <br />EHD 28-01 <br />01/16/08 <br />