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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME1 <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 />A1 1 a rol 0 T <br />6r7blq 7— <br />Page / of <br />Facility Address: <br />City: <br />Inspect'on D e: <br />/iLo (V <br />/ , <br />FA #: <br />0001 <br />PR #: <br />� b/?7 <br />Program Element: <br />2 8 <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 <br />type. <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: x`51 Ze 1pJ-!Sr <br />(>250 gallons) (>55 gallons and <250 gallons) <br />1 <br />Product Type: G�s <br />Total Capacity: 2 0 o O gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />(>250 gallons) (>55 gallons and <250 gallons) <br />2 <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />(>250 gallons) (>55 gallons and <250 gallons) <br />3 <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />(>250 gallons) (>55 gallons and <250 gallons) <br />4 <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />(>250 gallons) (>55 gallons and <250 gallons) <br />5 <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: <br />gallons <br />Total Capacity for Site: 2i G gallons <br />Comments: <br />EHD Inspector: <br />Reviewed Date: t� <br />By Initial: W' I .l � v <br />Entered Date: <br />By Initial <br />EHD 28-01 <br />01/16/08 <br />