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SAN JOAQUIN COUNTY _ <br /> E_NVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> East Main Street,Stockton,CA 9520273029" <br /> Telephone:(209)468=3420 Fax:(209)468-3433 Web:www.sjgov.orgJehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: lG Page Z of <br /> Alk) 16A T'�vc/� 711eA <br /> Facility Address: City: Inspecti Da <br /> fo Lo :r �/� OF <br /> Program Element: <br /> FA <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. <br /> Co lete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) U4containers (282 1) '#of Containers: I TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) t �— <br /> 1 Product Type: <br /> Total Capacity: 5_5 _ gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: J/ TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) �, <br /> 2 Product Type: lvy. <br /> Total Capacity: gallons .Install Date:' <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 D Product Type: Gf/ <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) U160'ntainers (2821) #of Containers: �TA#- <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> E 4 Product Type: <br /> { Total Capacity: Z &0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> ` 5 Product Type: <br /> Total Capacity:. gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> i <br /> 7 <br /> i <br /> EHD Inspector: Reviewed Date: Entered Date: _ <br /> + l By Initial: By Initial: l <br /> t <br /> EHD.28-01 <br /> ( 01/16/08 <br />