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(-4SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> 00 East Main Street,Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> J- 09 '5 TR A PL A 7_ ,q Page of <br /> Facility Address: Ins t' Dat <br /> / 5 6 UG S- L� �� GAT91?0 s U? <br /> FA#: PR# Program Eleme <br /> ODDo12 2� 3 : <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2t1320 gallons in tanks and containers over 55 gallons. <br /> Com Tete one box for each tank or each cumulative container product type. <br /> Ff Tank(2820) ❑ Containers (2821) #of Containers: TA#: a,,DjPJo�,� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 c Product Type: <br /> Total Capacity: / O d gallons <br /> (per?nk or cumulative for containers by product type) Install Date: <br /> VTank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: —� <br /> Total Capacity: /0 a 0 b gallons <br /> (per or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (282 1) #of Containers: TA#: i9 V6, 1^'7b <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: /o d gallons <br /> (per 14 <br /> or cumulative for containers by product type) install Date: <br /> CV/Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) /f <br /> � Product Type: <br /> Total Capacity: /o D 6 O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAM <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: 44 C7 a 4 gallonsTotal Capacity for Site: Q Q gallons <br /> Comments: <br /> EHD Inspector: Reviewed ered Date: 01 <br /> �t. By Initial: Initial: B <br /> EHD 28-01 <br /> 01/16/08 <br />