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SAN JOAQUIN COUNTY <br /> &E <br /> NVIRONMENTAL HEALTH DEPARTMENT <br /> 00 East Main Street,Stockton,CA 95202-30 <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 /> Page of <br /> Facility Address: City: Inspectio Dat <br /> -7 / rAl- wrs- AA 6 <br /> FA�O I vy ! 7 PR#• Progr m Element: <br /> L U / D 5-2 019ze / 2-971 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 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) #lof Containers: TA#: SJ�p tl/o�� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: p/ L <br /> Total Capacity: jr, G1 gallons <br /> (per tank or cumulative for contains by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM 0611 �(P <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: pi l/ <br /> Total Capacity: /O d e gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 19--'Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: oil/ <br /> Total Capacity: Z D D D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) VContainers (2821) #of Containers: TA#: Ob(1v ,ql r <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: G 6 <br /> Total Capacity: / Zy gallons G <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) 2"a�Containers (2821) #of Containers: TA#: B,,4( le�(eq <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 5 Product Type: a/ fi _ �,� <br /> Total Capacity: ! �d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Z gallons Total Capacity for Site: D gallons <br /> Comments: <br /> zU Z -f 4i <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: VO V4.0`� ByInitial: <br /> EHD 28-01 <br /> 01/16/08 <br />