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SAN JOAQUIN COUNTY <br /> *NVIRONMENTAL HEALTH DEPARTMi <br /> o00 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Na Al <br /> / GK /V /l zllo D/S/VAA17 i5XS Page / of 3 <br /> Facility Address: z c- Lqk, 0/� City: ��� Inspect' nDate: <br /> FA#: PR#: Program Eleme t: <br /> o ©lao3 Ll- a/ 1 X83 <br /> 1. <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: TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 1 Product Type: 1z, eQ� (OfF roa <br /> Total Capacity: o o gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> IP/Tank(2820) ❑ Containers (2821) #of Containers: TA#: 1),61 (P-14;Zj�P <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 5 Da Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> IP/Tank(2820) ❑ Containers(2821) #oContainers: TA#: /9�/[C 7,gq'7 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 ^�5p p Product Type: GAS � �7 <br /> Total Capacity: T, gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> EZ Tank(2820) Containers (2821) #of Containers: TA#: /9S/ /?7,?—'3 <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 4 6 O O Product Type: rr—A 5 <br /> Total Capacity: — gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 <br /> a 10 Product Type: <br /> Total Capacity: BFB gallons Install Date: P <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: va-f:" 1 O gallons Total Capacity for Site: �2 gallons <br /> Comments: L / <br /> 3/1!�, d� <br /> EHD Inspector: Reviewed Date: Entered Date <br /> C° By Initial: kp 1 (p_�3. Ey maul: <br /> EHD 28-01 <br /> 01/16/08 <br />