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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN' <br />o00 East Main Street, Stockton, CA 95202-302> <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 />SGM 0R/ <br />U/V1 r G <br />DOL iii VS <br />Page of <br />Facility Addres <br />City: � Q A � s' <br />,v <br />Inspe� o �� J� <br />U <br />1 <br />� <br />J SCA b -W <br />FA #: <br />6 0 2 Z <br />PR #: <br />3 <br />Program Element: <br />-z 9 3 7- <br />Tank/Container Information <br />Complete for all sites with <br />cumulative aboveground <br />storage of petroleum > 1320 gallons in tanks and containers over 55 gallons. <br />Complete one box for each <br />tank or each cumulative container product type. <br />lq-fa-;nk (2820) <br />❑ Containers (2821) <br />#of Containers: TA#: <br />1 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />n <br />Product Type: <br />Total Capacity: <br />/ 4 oro D gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />B' Tank (2820) <br />❑ Containers (2821) <br />#of Containers: TA#: 05) -712(Q j <br />2 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: E -R5 g <br />Total Capacity: <br />/ y 0 e) gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Er'TXank (2820) <br />❑ Containers (2821) <br />#of Containers: TAM D� <br />3 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />� <br />Product Type: %j Jq SI -6 <br />Total Capacity: <br />-5�6 6 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) <br />w (:ontainers (282 1) <br />#of Containers: TA#: <br />4 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: o <br />Total Capacity: <br />//0 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) <br />CTContainers (2821) <br />#of Containers: TA#: `h 712LQ <br />5 <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: �% <br />Total Capacity: <br />// <br />///0 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: <br />�% 7 Z'0 <br />gallons <br />FTotal Capacity for Site: `/ % Zv gallons <br />Comments: <br />EHD Inspector: / <br />Reviewed Date:Entered <br />By Initial: 4. (p, 04 <br />/ ) Date: <br />By Initial: J f J r <br />J /'.J <br />EHD 28-01 <br />01/16/08 <br />