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SAN JOAQUIN COUNTY <br /> til ENVIRONMENTAL HEALTH DEPARTME <br /> 600 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 /> nl n Page of <br /> Facility Address: I` � <br /> City: InsP on Da <br /> 273 6 S �a i s �r�✓ �� oz ' ° 7 <br /> FA#: PR#: Program EI a� <br /> y �� <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 <br /> W ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 7 C h gallons Install Date: <br /> Ud' <br /> ^�(pa tank or cumulative for containers by product type) <br /> &nk(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) �y <br /> 2 Product Type: � !� S ,3 <br /> Total Capacity: r'ro gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: _ <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: — - <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) — <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> G 132C 0/ <br /> EHD btspector: Reviewed Date: -.A Entered t / n Date: <br /> • By Initial: 'Y`� l By Initial: CMLX// <br /> EHD 28-01 <br /> 01/1"8 <br />