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SAN JOAQUIN COUNTY <br /> E00NVIRONMENTAL HEALTH DEPARTMIEast Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Far.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> S//— Y C Page_�of <br /> Facility Address: - City: Insp <br /> 3 Ll!• /?0NGA( 5-07/707 <br /> FA#: O O O 9.1 <br /> AI P/2� <br /> 000lik /�/ Pro'dg+ram Element: <br /> Tank/Container Information v' <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 /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: /9 6-/Zo 1,5k, <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 1 0 � 9 10Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 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<50 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 d 0 U gallons Total Capacity for Site: 0 gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date (� Entered Date: / <br /> By Initial: D X By Initial <br /> EHD 28-01 V CCCJJJ <br /> 01/I6/08 <br />