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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEI"�. <br /> --o00 East Main Street, Stockton,CA 95202-30:2s.- <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: V <br /> Page—/—of <br /> Facility Address: City: Inspection Da <br /> S-3 �s S)"K- do S o 9, <br /> FA#: U PR#: Program Element- <br /> 000 MLI_ sz� /6/ I zS7•3v <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 type. <br /> 01"Tank (2820) ❑ Containers (2821) #of Containers: TA#: p5 / (o f) <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: /0 900 gallons <br /> (per tank or cumulative foe conta�uct type) Install Date: <br /> Ele'Tank(2820) ❑ Containers (2821) #of Containers: A#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: O d D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [Tank(2820) ❑ Containers (2821) ##of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: (/•-lJ�� <br /> Total Capacity: D b gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> LTattk 2820 ❑ Containers 2821 <br /> ( ) ( ) #of Containers: TA#: �Q5 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: .gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) dKontainers (2821) #of Containers:Z' TA#,: t9 <br /> (>250 gallons) (>55 gallons Ilons) <br /> 5Product Type: �r�ea av <br /> Total Capacity: L llons Install Date: <br /> (per tank or emulative for containers uct type) <br /> Total Capacity this Page: ) 2 Z 1 gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed'$ Date: Entered Date:s By Initial L/,tj S ID'Q`/ By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />