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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 />Page <br />C ri <br />—L—of <br />Facility Address- <br />A 3-,y 6 N <br />City: <br />T/K <br />Inspect' %n Date/ <br />�/ �-97o <br />C, <br />FA #: <br />Oc)O 39Z-/ <br />PR #: <br />0 515- 879 <br />Program Element: <br />-2- <br />Tank/Container Information <br />Tank/Container <br />Complete for all sites with cumulative aboveground storage of petroleum >_ 1320 <br />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) <br />#of Containers: <br />TA#: <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: S V <br />e /z r, M <br />Total Capacity: L 7 0 � 14 gallons <br />Install Date: 13 % <br />(per tank or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: //AI%e <br />fa12,� �� f <br />Total Capacity: % 6( 7 7 9 gallons <br />Install Date: J 3 7/ <br />(per tank or cumulative for containers by product type) <br />VTank (2820) ❑ Containers (2821) <br />#of Containers: <br />TAM / <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: 3 6f gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: /? /` <br />V� Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: 19,5/4� 14 7 <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: � <br />' <br />j�/1,j C/f� /�I <br />Total Capacity: 6 -Lgallons <br />Install Date: Z J— <br />(per tank or cumulative for ontainers by product type) <br />VTank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: le l <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: �S <br />' / �n <br />V <br />0 S'g <br />Total Capacity: Z ?�3 gallons <br />Install Date: <br />or <br />(per tank or cumulative contain by product type) <br />Total Capacity this Page: '� gallons <br />Total Capacity for Site: L gallons <br />Comments: <br />EHD Inspector: <br />�' . (� <br />Reviewed <br />By Initial: <br />Da e: <br />Z' <br />Entered Date: <br />By Initial: <br />EHD 28-01 <br />01/16/08 <br />i <br />