Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEI <br />600 East Main Street, Stockton, CA 95202-302> <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 />/W %� i <br />Page -�— of _ <br />Facility Address: City: <br />Inspectio Date: <br />I . <br />FA #: <br />PR #: <br />Pro m ent: <br />a <br />- <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) ❑ Containers (2821) #of Containers: TAM �2 <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: j <br />Total Capaci 10 b 0 gallons h CA <br />Install Date: <br />( er tank or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) #of Containers: TAM le <br />2 <br />(>250 gallons) (>552allons and <250 gallons) <br />L' Product Type:. <br />Total Capacity-/ -' '� gallons h Shu p <br /> tall Date: <br />(per tank or cumulative for containers by product type) W044 NK(A <br />r tt <br />ank (2820) Containers (2821) #of Containers: �; TAM c3 <br />3 <br />(>250 gallons) (>5;5RIIons and <250 gallons) Y <br />Product Type. <br />Total Capacity: _ gallons �� Cc( <br />Install <br /> e for containers byproduct type) <br />X Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: I,� S�Pl 6l <br />Total Capacity: Cl.) gallons Install Date: LSCA a}' 1D <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) (V�In�stall Date: <br />Total Capacity this Page:.gallons <br />Total Capacity for Site: gallons <br />Comments, <br />L 101 , <br />0 14 <br />3 �°iV�1 <br />dztei� a <br />(n 1 � <br />i <br />z <br />EHD Inspector: <br />Reviewed Date: <br />Entered l7 Date <br />By Initial: <br />By Initial: ((l✓f% <br />EHD 28-01 <br />01/16/08 <br />