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A <br /> P SAN JOAQUIN COUNTY <br /> ► ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: r-- ��V�/S. - I <br /> ,_ Page of <br /> Facility Address: i City: / Inspect•on gate: <br /> /e,r� 91 <br /> Z DT <br /> FA#: PR#: Program Element: <br /> Tank/Container Inform <br /> Complete for all sites with cumulative aboveground storage of petroleu I <br /> 1320 gallons ' tanks and containers over 55 gallons. <br /> Complete one box for each tank or each c lve container duct type. <br /> ❑ Tank (2820) Containers (2821) #of Cont ' ers: A#: 0 �3-/ !7,9?1.3 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: D fb/L oTotal Capacity: Z. .S D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) el/containers (2821) #of Containers: TA#: o� <br /> 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) Product Type: /tom D d� <br /> 0 <br /> /'/ <br /> 7Total Capacity: j / A gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: O — 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: nc Z-/ <br /> Total Capacity: 2-Z-U gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) 91containers (282 1) #of Containers: / TA#: 6p <br /> (>250 gallons) (>55 gallons and<250 gallons) ,..`G <br /> 4 Product Type: <br /> Total Capacity: ' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) L"Containers (2821) #of Containers: / TA#: c�9n '707I 7 <br /> (>250 gallons) (>55 gallons and<250 gallons) ��-�� <br /> 5 Product Type: /Q� 0, L <br /> Total Capacity: � gallons _ <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: f 33 00gallons <br /> Comments: , <br /> EHD inspector: Reviewed Date: Entered Date: <br /> C By Initial: o By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />