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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME - <br /> ..00 East Main Street,Stockton,CA 95202-3tr,-_ <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 /> 7- oit Page—/—of <br /> Facility Address: City: Inspectio Da <br /> s0o AUT-0 P(,,��A T�19 C-y <br /> FA#: PR#: Progr m Element: I l ' <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 /> Com Tete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) ontainers (2821) #of Containers: TA#: l h <br /> (>250 gallons) (>55 gallons and<250 gallons) L <br /> 1 (gip Product Type: G / <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (282 1) #of Containers: 3 TA#: az? <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 1jI C) Product Type: D ! <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 9 Containers (2821) #of Containers: / TAM 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) �. r <br /> 3 2'10 Product Type: 04 / <br /> Total Capacity: t� gallons —o— <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: �TAM Z2 0 (L"XI) <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 2�fj Product Type: O/ <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers 6y product type) Install Date: <br /> 1!TTank(2820) ❑ Containers (282 1) #of Containers: TA#: — <br /> (>250 gallons) (>55 gallons and<250 gallons) __ter <br /> 5 !�bD Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: J gallons Total Capacity for Site: ((070 gallons <br /> Comments: f <br /> L � <br /> o r <br /> EHD Inspector: , Reviewed Date: // Entered te: <br /> ' By Initial: By Initial: <br /> EHD 28- <br /> 01/16/08 <br />