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_ SAN JO4-QUIN COUNTY <br /> R <br /> ENVIRON-MENTAL HEALTH DEPA R FNIEN'INW4 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility,Na 0 r n� ,t e 6./'� Page / of / <br /> G� e' b <br /> Facility Address: ,r� City: Inspeea Date- <br /> Facility <br /> S 2 !!� GliD o �✓ /al/�I <br /> FAA: PR#: Progra Element: <br /> v <br /> / a65S D5a 9 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. <br /> _L <br /> Complete one box for each tank or each cumulative container product <br /> Yd'l ank (2820) ❑ Containers (2821) #of Containers: e %TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 2se) gallons Install Date: <br /> (pa tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: ! <br /> (>250 gallons) (>55 gallons and<250�PomN l <br /> 2 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 /> (>2m gallons) (>55 gallons and<50 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons i ! <br /> stall Date: ! <br /> (pa rook or cumulative for containers by product type) l <br /> i <br /> ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAT: <br /> ! <br /> (>250 gallons) (>55 gallons and<50 gallons)4 Product Type: <br /> � Total Capacity: <br /> apa_iry.e_for vontainers ov prod�cgx taylpleo; <br /> n11Sia11r <br /> l <br /> aLV. <br /> l t <br /> ❑ Tank (2820; ❑ Contai.-irrs (2321) #of Containers: TA#: <br /> 250 tons) f>55 gallons and<250 gallons) <br /> (� � roduct Ty.-,e: <br /> _ — -- --- <br /> all___ <br /> Dtal Caper-iy': ." cua ...S 12111 "C: — <br /> t tper eanY or rwnuiauve For eommnet%F.� <br /> I <br /> / 3 Zo --- <br /> i <br /> , 1 <br /> EHD Inspector Reviewed Date: Entered Date <br /> By Initial: 1,.0 him <br /> al <br /> Inal- <br /> v •v ll ISS 1 <br /> Ll ID 23-01 <br /> 01.!6103 <br />