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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <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 />�' J <br />A INN <br />Page 7— of <br />G` <br />Facility Address: <br />City: <br />Insp�i Daty: <br />FA #: <br />PR #: <br />Program El ment: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage <br />of petroleum > 1320 gallons in <br />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: TA#: <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />d <br />Product Type: <br />Total Capacity: l d O b gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />V Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: �� eq <br />Total Capacity: FO gallons <br />,S.Arc <br />(per tank or cumulative for containers by product type) <br />Install Date- <br />`fi" ank (2820) El Containers (2821) <br />R <br />#of Containers: TA#: D5(�) Q3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />3 <br />Total Capacity: -�� gallons <br />Product Type: <br />n <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 0,,Tj Ze ( � <br />(>250 gallons) (>55 gallons and <250 gallons) <br />4 <br />Total Capacity: 3 " gallons <br />Product Type: ��f yi7�/q <br />��/ (' , Or <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 />5 <br />' <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: gallons <br />Total Capacity for Site: gallons <br />Comments: <br />EHD Inspector: <br />Reviewed <br />By Initial: <br />Date: <br />Entered Date: <br />By Initial: L C� <br />EHD 28-01 <br />01/16/08 <br />