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... ---------- <br /> ... ........ <br /> SAN JOAQUI[N 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 /> fit <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORTM �t <br /> vir <br /> Facility Name: Page of <br /> A-7A j, 7- p N &/_-c A NY)�,W —k— <br /> Facility Address: 1 Iq IF City: fA r/0 'V lnqrtTte- <br /> P /F <br /> '�_V-3 9-- 14/,G 19 '--PC— (7 y ;v9&4Z <br /> FA#: PR#: Program Elementf <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum �!1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> El Tank(2820) E"Containers (2821) TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> P'duct Type: 7� 14, (/_ <br /> Total Capacity: 0495L gallons Install <br /> I I . <br /> 'product type) all 0= <br /> (per tank or cumulative for contain by Install a <br /> -I_- <br /> El Tank(2820) 2.Containers (2821) #of Containers: TA#: !7(_�/ <br /> 2 (>250 gallons) (>55 gallons and<250 gallons) Product Type: 12 :1� <br /> Total Capacity: _jgR_r_gallons <br /> (per tank or cumulative for Zo—ntg-meirby product type) Install Date. <br /> I <br /> El Tank(2820) RKContainers (2821) #of Containers: TAM 6'6_1 7 3 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: - gallons Install Date: <br /> (per tank or cumulative for containe'Kby product type) <br /> EIlk(2820) 0 Containers (2821) <br /> T 'IT #of Containers: TA#: <br /> 4 (>250 gallons) (>55 gallons and<250 gallons) Product Type: /-e '65,62 <br /> Total Capacity: To b gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Q--'rank(2820) El Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 00, Product Type: Z� <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulativa4Tr containers by product type) <br /> Total Capacity this Pag!Q2j" gallons I Total Capacity for Site: gallons <br /> Comments: <br /> 11M Fro <br /> I left f!!f(A) 11" 9/71D 12 <br /> EHD Inspector: Reviewed Date: -- Entered Date- <br /> By Initial: I By Initial: <br /> L_ I <br /> EHD 28-01 <br /> 01/16/08 <br />