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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPAR.TMEN" <br /> 600 East Main.Street,Stockton,CA 95202-30rwo" <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> l� tl d L � Page of <br /> l <br /> Ins ectio Date: <br /> Faci rty Address: City: p � <br /> z_ 6 - v,E. F S C,q SCI�' $ `b <br /> FA#: PR tt: r Program lenient: <br /> 0 0 0 7ia 9 c2$ 6) S 4 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative con iner product <br /> ❑ Tank(2820) Containers (2821) #of Containers: j TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> I Product Type: L12,4 710 I"- Q/ <br /> Total Capacity: /f o gallons <br /> (per lank or cumulative for containers by product type) Install Bate: <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: _ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> `' f Product Type: <br /> Total Capacity: l k gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 216ontainers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 .� Product Type: /4 0%a/z—0G <br /> Total Capacity: / d gallons - <br /> (per tank or cumulative for containers by product type) Mail Date: <br /> E� Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: 4.r 7�' G7 / <br /> Total Capacity: .Sp 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 /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: go gallons Total Capacity for Site: (:tllons <br /> Comments: <br /> 3 Z ";I-At Lo 0'V5 —t ev 6 <br /> EHD]nspcoor: Reviewed Bate: Entered Date: <br /> • By Initial: Vt� $,jp.() By Initial: <br /> 91100 <br /> EHD 28-01 <br /> 01/16/08 <br />