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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN' <br /> 600 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 Name: , <br /> / W � J� VC ) �O/v PageOf I <br /> Facility Address: � tAIA r�� / © �� Inspection Date: <br /> FA#: PR#: Program Element: w <br /> 5� Z <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 /> �nk(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: � <br /> Total Capacity: / b OD 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) 9� <br /> 2 Product Type: <br /> Total Capacity: j0t) U gallons k'� <br /> (per tank or cumulative for containers by product type) Install Date: <br /> (2820) ElContainers (2821) #of Containers: TA#: <br /> (>250 gal o (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: �.. <br /> allons(per tank or cumulative for contproduct Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: � 7 r 3 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: 0/ <br /> Total Capacity: b-6 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons —'��- <br /> (per tank or cumulative for containers by product type) Install Date: , <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: ` <br /> j> <br /> I <br /> - 1 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> ✓ By Initial: <7• By Initial: D <br /> EHD28-01 <br /> 01/16/08 <br />