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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME, <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 /> 111 11'J — ' L yl N� .�rl'f'!//G Page of <br /> Facility Address: City: Inspecti n Dat <br /> /S i�'WCy (3Z—kW Arc q- i V o -� <br /> FA#: PR#: Program Ele ent: <br /> C2 o 01iJ'719,Y z S3 Z <br /> Tank/Container Information <br /> Complete f r 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 /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: 1P ee <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: (� gallons <br /> (pyank or cumulative for containers by product type) Install Da <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> ons) (>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 /> [Tq5- <br /> EspectK Reviewed v u tfta i Entered Date: <br /> By Initial: 'L?j By Initial: / <br /> EHD 28-01 <br /> 01/16/08 <br />