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SAN JOAQUIN COUNTY <br /> ,AV[RONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-302y <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Mame: 1/ <br /> Page <br /> Ho <br /> �� G � of <br /> Facility Address: City: I77, <br /> ' n Date: <br /> l ? b 4- C;o L� S 1 ; s c N 2�0S <br /> FA#: PR#: Program Element: <br /> Q O 1 5/9 4L�40 1 <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: pT�A�#� hal Ly/ 9 <br /> 1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: <br /> Total Capacity: /a o o gallons <br /> (per tank or cumulative for containers by product type) Install Date- <br /> (per <br /> (2821) #of Containers: / TA#: /9 h/ 4f <br /> aank(2820) 7a2� <br /> (>250 gallons) (>55 gallons and<250 gallons) J <br /> 2 Product Type: 1�1/,q s <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> nk(2820) Ei C&tainers (282 1) #of Containers: TA#: o2- <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 3 Product Type: <br /> Total Capacity: Z-T`v gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: (� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: X— rY C O Q� <br /> Total Capacity: 3�U gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 2 Containers (282 1) #of Containers: 3 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: 1 b 5 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 'L C-)6 gallons I Total Capacity for Site: Z a U gallons <br /> Comments: <br /> dw S � ZOA7 o c aG�V <br /> V <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: L� -3o-1 By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />