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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN'I.,aaaa} <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web.www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> leANS o T Page of� <br /> Facility Address: I /�� City: Inspect) D it- <br /> 2 S MN /e109A /&^ - �G rz �iz <br /> FA#: PR i7— Program Element: <br /> 6 z/ 9, <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 /> Tank(2820) ❑ Containers (2821) #of containers: TAM jq,h/'T3�� _ <br /> (>250 gallons) (>55 gallons and<250 gallons) Type: <br /> � a /'0 2 O <br /> 1 Product T e: ! t� <br /> Total Capacity. '3 �rZgallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> link(2820) ontainers (2821) #of Containers: TAM Z .6 <br /> (>250 gallons) >55 gallons and<250 gallons) lil/�j ,f l O!zz _ <br /> 2 � Product Type: <br /> Total Capacity ,9 Ballo <br /> (per tank or c e fm containers by product Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 roductType: � <br /> Total Capacity: gallons Install Date: y /G Ty1 <br /> �er�anker clue for contamers by prodnct type) <br /> ❑ Tank (2820) Containers (2821) #of Containers: Z TA#:—rh ® 3 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: L/)/ <br /> Total Capacity: L/ C-) 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 /> 5 Product Type: <br /> Total Capacity: gallons Mall Date: <br /> (per tank or cumulative for containers by prod <br /> Total Capacity this Page: 0 Q gallons I Total Capacity for Site: /0/0 hallons <br /> Comments: v O 77 <br /> Jr✓�� 419 <br /> /�Ld <br /> a r <br /> EHD Inspector: < -Reviewed Date: Entered Dat . <br /> / By Initial: ' d By initial: <br /> EHD2"I <br /> 01/16/08 <br />