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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMET <br /> 600 East Main Street, Stockton,CA 95202-300 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: ( g <br /> r c AV l D d'WZA Pae of <br /> Facility Adamss. / n' City: Inspection Date: <br /> FA#: PR#: Program Element: <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 Bre l IP <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 1A Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative or containers by product type) Install Date: <br /> ❑ Tank (2820) containers (2821) #of Containers: TAM — 6 <br /> (>250 gallons) (>55 gallons and<250 gallons) ,j ^ �/ 0` <br /> 2 � r� Product Type:_ Ji/ ,/ <br /> Total Capacity: -b` gallons <br /> (per tank or cumulative for containers by product type) Instal] Date: <br /> )Dank(2820) El & <br /> Containers (2821) #of Containers: TA#: 6,-2 ) <br /> (>'250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: (I�+"Vl rw <br /> (per tank or cumulative fo containers by product type) <br /> `C Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 $U Product Type: AI <br /> Total Capacity: 2 gallons Install Date: UJAV" <br /> l <br /> (per tank or cumulative for containers by product type) <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: fl6a.D 1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: G o <br /> Total Capacity: J() gallons Install Date: <br /> per tank or cumulative for containers by product type) <br /> Total Capacity this Page: -AL� gallons Total Capacity for Site: 'Z70gallons <br /> Comments: <br /> i <br /> EHD Inspector: Reviewed `,/ Date: Entered Date: <br /> By Initial: i?A f K- `I By Initial: <br /> EHD 28-01 <br /> 0l/16/08 <br />