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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME.,w <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: D lsgv` Page / of <br /> Facility Address: City'. Iaspect i nDa[e•, r� <br /> 7-J- AF - t o P y <br /> FA#. PB#: Program lement: <br /> 0 01 zz .SZ-7 /t2 z X 77 <br /> 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 <br /> plank(2820) ❑ Containers (2821) #of Containers: TA#: P5�) lip r2q__ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type:0.4� <br /> Total Capacity: / b my Z) gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) Q Containers (2821) #of Containers: '✓ TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: /.,irG f 72-� 6 / <br /> Total Capacity: // 6 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: <br /> Total Capacity: 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 /> 4 Product Type: <br /> Total Capacity: 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 /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date' <br /> Total Capacity this Page: 0 gallons Total Capacity for Site: Zogallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date <br /> C By Initial: V,t"/ ZP Bylnitial: <br /> EHD 28-01 <br /> 01/16/08 <br />