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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> ' -600 East Main Street, Stockton,CA 95202-302Y <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 /> d � -r d F C-A LI F O M( f� Page—/ _of3-- <br /> Facilitv City: <br /> Inspecti n Date: <br /> l 5 5--rte 2/-711/ <br /> PR#: Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum L>1320 gallons in tanks and containers over 55 gallons. <br /> Com Tete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: 'fA#: t y <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 1 Product Type: <br /> Total Capacity: Z o 00 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) Vcontainers (282 1) #of Containers: 7 <br /> (>250 gallons) (>55 gallons and<250 gallons) y <br /> 2 uct Type: A <br /> Total Capacity: gallons <br /> (per alive for containers by product type) Install Date: <br /> 17 <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: d 51 1 1(p <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 3 /3 D Product Type: ,�/ l✓ <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Ly' Tank(2820) ❑ Containers (2821) #of Containers: " TA#: nc5-/ 7 1 <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 4 � Product Type: O i <br /> Total Capacity: '2- O gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: 2±1:7 <br /> (>250 gallons) (>55 gallons and50 gallons) <br /> 5 I�2Product Type: 14 f <br /> Total Capacity: Z D Od' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 3Lacf Qgallons Total Capacity for Site: O !J� gallons <br /> Comments: <br /> #2 3 <br /> nC D eel Dry <br /> c1 <br /> EHD Inspector: eviewed Date: Entered Date <br /> By Initial: By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />