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I SAN JOAQUIN COUNTY <br /> • ?NVIRONMENTAL 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: -Lee�n Page, Of <br /> Facility.Address: City: Inspection Da e: <br /> d' 7lD kve�Ml55 ?� <br /> FA#: ,p PR#: O H � � Progra p'lemei�: <br /> L <br /> Tank/Container Information <br /> Com Tete for all sites with cumulative aboveground storage of petroleum z 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#: &5/ W 1 '6 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: 22"., <br /> Total Capacity: / Z o & D gallons I tall D te: V-6�fl ,S <br /> (per tank or cumulative for containers by product type) <br /> 11 <br /> Gunk(2820) ❑ Containers(2821) #of Containers: TA#: 0,5' 'a2 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: I„r,.q <br /> Total Capacity: gallons Install te: ��DS 4 I $' <br /> (per tank or cumulative for contain b product type) <br /> �ll <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: k <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> $ Product Type: <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: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: b' <br /> By Initial: By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />