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SAN JOAQUIN COUNTY <br /> _ ENVIRONMENTAL HEALTH DEPARTME./ <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: <br /> G O Page � of z <br /> Facility Address: City: Ins pe i ate: <br /> )9 r, D If CL G fil D Ib ' 641? <br /> FA#: PR#: Progr m anneal: <br /> ono 97 / 3 1 Szz. 2o/ z- p3/ <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 /> -- `` <br /> Complete one box for each tank or each cumulative container product e. <br /> 91"I'ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> \ (>250 gallons) (>55 gallons and<250 gallons) <br /> 1, Product Type: VA??"-QJ <br /> Total Capacity: [ o d O gallons <br /> (pertankor cumulative for containers by product type) Install Date: ty <br /> Q" Tank(2820) El Containers (2821) #of Containers: TA#: D`Jllvy L <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type:; <br /> Total Capacity: / 000 gallons <br /> (per tank or cumulative for containers by product type) Install Date: '' ''pp.. <br /> ank <br /> (2 20) Containers (2821) #of Containers: TA#: nh( [pal <br /> >250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: Z U D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) LYContainers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: Z&"M Z° <br /> Total Capacity: f .S gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> ElTank(2820) M//Containers (2821) #of Containers: J TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: p/ (� <br /> Total Capacity: BUD gallons <br /> (per lank or cumulative for containers by product type) Install Date: / <br /> Total Capacity this Page: 2- �' gallons Total Capacity for Site: Z 6 7 gallons <br /> Comments: <br /> L 20 <br /> EHD Inspector: Reviewed DtLj Entered Date: <br /> C I n By Initial: U,tj By Initial: <br /> EHD 2"1 J <br /> 01/16/08 , <br />