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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMET <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 Name: <br /> L Q D v("T.s Page of <br /> Facility Address: City: Inspectio Da : <br /> / 2686 o�kx o �% `/s- ("T <br /> FA#: PR#: Program FIegnenr <br /> 0 0o 'r 7,?,7-3-3 Z F31 <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: •TA#: t5 b <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 1 Product Type: <br /> Total Capacity: /�S gallons <br /> (per tank or cumulative for containers by product type) NVY <br /> Install Date: <br /> ❑ Tank(2820) C 'Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) _910 <br /> 2 Product Type: <br /> Total Capacity: �Z 5 d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) eContainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: p <br /> Total Capacity: :3 6 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank 2820 LA Containers 2821 _ <br /> ( ) ( ) #of Containers: �� TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: Z � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) C/Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: a r�,fi� D <br /> Total Capacity: Z Z D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page:l gallons TTotal Capacity for Site: gallons <br /> Comments: <br /> c <br /> EHD Inspector: Reviewed Date: c( Entered Date: <br /> ` By Initial: (� "0° By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />