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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEI <br /> 600 East Main Street,Stockton,CA 95202-30 9 <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 /> 3 7" vCr� AUTO f'/ �ZA Page I of y <br /> Facility Address: N T� IN �— le ,tity: -� Inspe Da <br /> o o �/K�/N, / 0 <br /> FA#: PR#: Program Element: <br /> 2- Y3 "'- <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 /> Ig/Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Z0 C' O Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ER/Tank(2820) ❑ Containers (2821) #of Containers: TA#: ©W/ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 O O � © Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> FtrTank(2820) ❑ Containers (2821) #of Containers: TA#: 0,5-7 ppb?0 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: 0 P7 O 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 1] Tank (2820) 2 Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: O t <br /> Total Capacity: S'a D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [eTank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) l <br /> 5 Product Type: (y <br /> Total Capacity: S G d gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: y Q O gallons Total Capacity for Site: 2 Z,o gallons <br /> Comments: <br /> 71/ <br /> EHD inspector Reviewed Date: Entered Date: <br /> By initial: W rJ 6/w(4 By initial: YT <br /> EHD 28-01 <br /> Ol/16/08 <br />