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_ SAN JOAQUIIN COUNTY _ <br /> NV IRONMENTAL HEALTH DEPARTMEN- <br /> 600 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: j j 6 PiTOW <br /> �� N Page�_of . <br /> Facility Address: City: Imp" on Date: <br /> z TtG -7 <br /> PA 8: PR B: Program Eleme t• <br /> p,ra g z 8 U <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 /> P,'ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) T <br /> 1 Product Type: � ,� /� d I <br /> Total Capacity: S'a/) gallons <br /> (per or cumulative for containers by product type) Install Date: <br /> C9'Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) D <br /> 2 Product Type: /1-i n <br /> Total Capacity: �Z a gallons <br /> (per tank or cumulative or containers by product type) Mall Date: — <br /> ❑ Tank(2 20) Wca�ontainers (282 1) #of Containers: Y TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: /110 l dam-- D 1 ( i <br /> Total Capacity: /,7-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) MIContainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 4 Product Type: !'h 17-0/Z-- O/ C/ <br /> Total Capacity: // 10 gallons <br /> (per tank or cumulative liarcontainers by product type) Install Date: <br /> El Tank(2820) Containers (282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: /?7 e 1—p h/ Di l/ <br /> Total Capacity: /�r) gallons <br /> (per tank or cumulative for contamers by product type) Install Date: <br /> Total Capacity this Page: O gallons I Total Capacity for Site: j )� gallons <br /> �ttte � l <br /> EHD Inspector v ByReviewed v Date:- <br /> By <br /> •10 Entered <br /> iInnitiial: lit <br /> EHD 2M 1 a� <br /> 01/16/08 <br />