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SAN JOAQUIN COUNTY. <br /> %,OENVIRONMENTAL HEALTH DEPARTMENTV <br /> 600 East Main Street,Stockton,CA 95202-302T <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 /> S-KsS �A/7"AfR PV1 Page of <br /> Facility Address: Cf . J_/�a Iaspectlop D}te: <br /> AICA CAM? w ���- <br /> FA#: PR#: ' Progi <br /> 8 3 9 v er a _ -2-c6gD <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 <br /> allons.Com lete one box for each tank or each cumulative container product <br /> Tank(2820) ❑ Containers (2821) #of Containers: i TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) D� J <br /> 1 Product Type:Total Capacity: Sn goo Install Date: <br /> (pea 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 /> 2 Product Type: � <br /> Total Capacity: gallons Mall Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Mall Date: 1 <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: p Q gallons Total Capacity for Site: dD gallons <br /> Comments: <br /> EHD Inspector. Fevicwed Date: Entered Date: <br /> G- By Initial: t 1-(D,p By Initial: <br /> EHD 2"1 l <br /> 01/16/08 <br />