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T SAN JOAQUIN COUNW,. y <br /> t NVIRONMENTAL HEALTH DEPARTMEN' <br /> '716000 East Main Street,Stockton,CA 95202-30 <br />` { Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> s , <br /> Facility Name: O Z,I/ Page <br /> I; Facility Address- City: inspectio'o Date, <br /> s FA#: PR#: Pr0 am lemenl: <br /> 19190 `7-l <br /> Tank/Container` Information <br /> t Complete for all sites with cumulative aboveground storage of petroleum 2,1320 gallons in tanks and containers over 55 gallons. <br /> Com to one box for each tank or each cumulative container product type. <br /> ❑ Tank (2820) iKcontaine. rs (2821) #of Containers: %­" TA#: Q 6_f 7 / ?c' - <br /> (>250 gallons) (>55 gallons and<25O gallons) <br /> =Product Type: C� " <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) *. . Install.Date: s <br /> Tank(2820) 0 Containers (2821) . #of Containers: TA#: <br />€ (>250 gallons) (>55 gallons and X250 gallons) <br /> Product Type: d rD l <br /> Total Capacity: $ J gallons <br /> Install Date: <br /> (per tan r cumulative for containers by-product type) <br /> Tank(2820) ElCo tainers (2821) -"Ytbf-Containers: TA <br /> (>250 gallons) (>55 gallons and<250.gallons) " <br /> 3 / �. � _ Product',Type: <br /> Total Capacity. _ r •:D' _, gallons <br /> (per tank or cumulative-for containers by product type) --Install Date: <br /> �Eank� 2]8�0ontainers (2821) #of Containers:--y`' . TAI.#:ns) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: 2--6 gallons <br /> (per tank or cumulative for containers by product type) Install Date' <br /> 7. <br /> ±eorank(2820) D Containers (2821} #of Containers: TA#:..�©�'f <br /> (>55 gallons <br /> (>250 gallons) and X250 gallons) <br /> 5 -"` `�.Q Product:Type: lP1'T�' a� <br /> Total Capacity: _ .l , gallons <br /> w. (per tank or cumulative for contiiners by product type) Install Date: <br /> Total Capacity this P gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: j Reviewed Date: � ' Entered Date: <br /> By Initial:' yC6,0 By Initial: <br /> f EHD2MI <br /> 01/16/08 �� <br />