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SAN JOAQUIN COUNTY <br /> —iNIRONMENTAL HEALTH DEPARTME <br /> f ' 600 East Main Street,Stockton,CA 95202-3%,-j <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> 14 p Gr A C, Page of � <br /> Facility Address: City: Inspec on Date: <br /> 004 CoLE 51 sC N I <br /> FA#: PR#: Program Element: <br /> d 0 '�Zt -z .SSI <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 /> FteTank(2820) ❑ Containers (2821) #of Containers: TA#: "-� (p f 9 <br /> (>250 gallons) (>55 gallons and<250 gallons) r-- <br /> 1 Product Type: ���X.,y��/ <br /> Total Capacity: - /a G b gallons <br /> (pertankor cumulative for containers by product type) Install Date: <br /> I.�'Y'ank(2820) 11k6ontainers (2821) #of Containers: TA#: le 702 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: _fi�,i._q <br /> Total Capacity: &9-0gallons z'T <br /> (per tank or cumulative for containers by product type) Install Date: <br /> WC(2820) LIYContainers (282 1) #of Containers: 1 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) 1 <br /> 3 Product Type: cce /4N T <br /> Total Capacity: -2-/4.0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: /�VIR <br /> ( oV 6eSA <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: / l� <br /> �t'l <br /> (>250 gallons) (>55 gallons and<250 gallons) 1 <br /> 4 Product Type: ,CJ �� ��d <br /> Total Capacity: 3 gallons f G,� c� <br /> (per tank or cumulative for containers by product type) Install Date: (M cUA <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#:z /��' LZ <br /> �\ <br /> (>250 gallons) (>55 gallons and<250 gallons) ✓ �lQ " p2 U Q�Il <br /> 5 Product Type: <br /> Total Capacity: 1b5 gallons � V(per tank or cumulative for containers by product type) Install Date: r <br /> Total Capacity this Page: rj 6 gallons] Total Capacity for Site: Z O d gallons <br /> Comments: <br /> d/✓ ,zSG I— T o �aGry <br /> V <br /> -2-- 3 1� I <br /> EHD Inspector: Reviewed Date: / Entered Date:' ` <br /> By Initial: �� r .�0 t�G By Initial <br /> EHD 28-01 (-�^^ro (/ <br /> 01/16/08 rt2ri I I <br />