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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME <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 />C./C !yq <br />Page _� of <br />Facility Address: City: <br />�� S /vL i� % C ` <br />Inspecpion Date: <br />o <br />FA #: <br />FA coo G * <br />PR #: <br />FRaJI 63 Z? <br />Program Element: <br />Tank/Container Information <br />Complete for al 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#: 41,9 77 <br />(>250 gallons) (>55 gallons and X250 gallons) <br />Product Type: <br />Total Capacity: / 0 6 Y gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />MM 4fContainers <br />Tank (2820) (2821)aq #of Containers: TA#: B,o�/ 1z,') 7?3 <br />2 <br />(>250 gallons) (>55 gallons and all ) 10� / <br />�11�� Product Type: Gl/�,sT� <br />Total Capacity: allons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Wank (2820) *Gntainers (2821) #of Containers: TA#: �951&g?!7 <br />3 <br />(>250 gallons) (>55 gallons and < alr�� lo <br />_��vc� Product Type: AIA S rte' <br />I 'ons <br />Total Capacity: '— `� ga u <br />Install Date: / <br />(per tank or cumulative for containers by product type) <br />VT( 2820) Containers (2821) #of Containers: TA#:`1P DgO <br />4 <br />>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: / FO gallons Install Date: /,�� <br />(per tank or cumulative for containers by product type) <br />Ank (2820) Containers (2821) #of Containers: TA#: z � 1 le� <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: /.S ; gallons of ---�S'.firz, <br />(per tank or cumulative for containers by product type) Install Date. <br />Total Capacity this Page: gallons <br />Total Capacity for Site: gallons <br />Comments: <br />Z �y6AWelzA 2019 Q36-�z3 <br />EHD Inspector. <br />-7 <br />Reviewed nood <br />By Initial: <br />Entered Date: <br />By Initial:�Z(7 O <br />�. <br />EHD 28-01 <br />01/16/08 <br />