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SAN JOAQUIN COUNTY <br /> .ENVIRONMENTAL HEALTH DEPARTMENT <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: l / <br /> 7 O 5 N U G �l N 6— Page C of <br /> Facility Address: City7(?-[16 <br /> : Inspen Date: <br /> 2 o Tv - <br /> FA#: PR#: Program Element: <br /> 000 3 ?Q Y- 5'1� Z 83 <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 /> ❑ Tank(2820) 04<Containers (2821) #of Containers: TA#: Q�$ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: (3 / <br /> Total Capacity: 2 s b gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) containers (2821) #of Containers: --3 TA#: O'IL- <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: /11/ v <br /> Total Capacity: /2>/,5 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: TAk. <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: lti <br /> Total Capacity: .�s gallons <br /> (per tank r cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: ._,T : <br /> 4 <br /> (>250 gallons) (>55 gallons and<250 gallons) XA aaz <br /> Product Type: & <br /> Total Capacity: d O O v gallons <br /> (per tank or cumulative4br containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <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: 40 gallons Total Capacity for Site: / 02/'90 gallons <br /> Comments: <br /> 42 <br /> EHD Inspector, Reviewed Date: Entered Date: <br /> By Initial: k)A '1_-y\-D By Initial: 41S <br /> EHD 28-01 <br /> 01/16/08 <br />