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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME <br />600 East Malin 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 />Facility Name: I Yt 1,(l-ru-v I v 1v V- jr /y PG ICr Ns 6 <br />4`6,9ty/ <br />Page 1_ of <br />Facility Address: r� �v �� 2 ' City, r G d �� <br />�'77����DD . / LLt� & ' I <br />Inspection D e: <br />FA #: <br />PR #: <br />J-/ 2 0 0 <br />Program Element: <br />-ZT3 -� <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum z 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) <br />#of Containers: <br />- TA#:��Q <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: 9 0 o 0 gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: 5/ z? 13Z <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Total Capacity: DDD <br />Product Type: <br />b gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Id/Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: X0514%5 o? -X <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />j ,, r C- <br />Product Type: 4r.6 <br />f�-� -A <br />Total Capacity: Ta0 gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: 651IfCog —3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />—T <br />Product Type: <br />Total Capacity: D 4 d gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />2 Tank (2820) ❑ Containers k 821) <br />( 50 gallons)' (>55 gallons and %Il Ilons) <br />#of Containers: <br />—�7— <br />TA#: 02. <br />5 <br />ProductType: ype: �/ f p /Qj' <br />" <br />oy/ <br />To I -Capacity: O gallons <br />- <br />(per tank or cumulative for containers by product type) - <br />Install Date: <br />Total Capacity this Page: 2_ <br />gallons <br />Total Capacity for Site: D iia gallons <br />Comments: <br />EHD Inspector: <br />gt <br />Reviewed Date: <br />By Initial: J f �� .1. <br />Entered I/n Date <br />By Initial: <br />EHD 28-01 <br />01/16/08 <br />