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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: <br /> �r r&vV i &NPage of <br /> Facility Address: City: InspecIE <br /> 'on Dat <br /> Lo cv+(C. 1n� 1- G i r , V2 � b t <br /> FA#: PR#: Pr ogr m�lement: <br /> b7 ? <br /> o z � 2 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2-1320 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#: e) <br /> (>250 gallons) (>55 gallons and<250 gallons) " <br /> 1 Product Type: < <j e��� l��— 1j�L <br /> Total Capacity: 7 gallons Install Date: <br /> (per tank or cumulative for c tainers by product type) <br /> Tank(2820) 11Containers (2821) #of Containers: TA#: <br /> d Jr�5810,f <br /> xm(> 50 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: b gallons Install Date: <br /> (per tank or cumulative for—containers by product type) <br /> X Tank(2820) ❑ Containers (2821) #of Containers: TA#: ��/-�`�4-:< <br /> (>250 gallons) (>55 gallons and<250 gallons) ' <br /> 3 Product Type: � } ems. ru&-L <br /> Total Capacity: 13 6 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> I Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: e9S L U0, <br /> Total Capacity: 2. 1(>13 U gallons <br /> (per tank or cumulative for con ainers 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: 9-16 0_0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: ( gallons <br /> Comments: r U I GQ, —r/' (i G �— <br /> r uu � iv W <br /> EHD ector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> z?d <br /> EHD 28-01 <br /> 01/16/08 <br />