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SAN JOAQUIN COUNTY <br /> MRONMENTAL HEALTH DEPARTMEN <br /> o00 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 / G J/ ` <br /> lt� L14Al / 9 7_11,r"/ Page � ofy <br /> Facility Address: 1 City: Insion Da <br /> 'C/UI GUS ✓ � 0� <br /> FA#: PR#• Program ement: <br /> 6511e b 2- 23 -2,— <br /> Tank/Container <br /> - 3 -2,—Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 2 0 00 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> P Tank (2820) ❑ Containers (2821) #of Containers: _ TA#: ffr-T <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 3 0 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (282 1) #of Containers: / TA#: n'5-/ (Q c�8 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: ;V nFr/ <br /> Total Capacity: S-r gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) [containers (282 1) #of Containers: TA#: 05-1 4C 33$ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: —5,_�_ gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) 'ff Containers (2821) #of Containers: TA#: /q,h D Z2 31a4Q <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: 9'Y gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 2 gallons Total Capacity for Site: Z gallons <br /> il <br /> Comments: <br /> EHD Inspector: Reviewed 1 Date: Entered Date: <br /> 4�2 By Initial: �{.! 1�Q.D$ By Initial !1 <br /> EHD 28-01 (� u <br /> 01/16/08 <br />