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SAN JOAQUIN COUNTY <br /> *ENVIRONMENTAL HEALTH DEPARTMENA <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; f <br /> r— 1� t C)b �U�S Z/`G, Page 1- of <br /> Facility Address: City: Imp 'on Da <br /> FA#: PR#: Program Element: <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 /> ❑ Tank(2820) VContainers (2821) #of Containers: 2 TAM awl-/S'"(>250(>250 gallons) 5 gallons and<250 gallons) <br /> 1 Product Type: l��p m;c 4 L -rt 4M FG J U A <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (282 1) #of Containers: Z TAM J�Qrj <br /> (>250 gallons) 55 gallons and<250 gallons) <br /> Product Type: /� Gln q r1 d 1- <br /> Total Capacity: t c C� gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) Containers (2821) #of Containers: 2 TA#: / S(P <br /> (>250 gallons) (>55 gallons and<250 gallons) SIR <br /> 3 Product Type: SIR D 641 l) � ,� 11 �t '- <br /> Total Capacity: / [� gallons Install Date: <br /> (per tank or cumulative for c�+[ainers by product type) <br /> ❑ Tank(2820) VContainers (2821) #of Containers: Z TA#: 46­16167 <br /> 004 (>250 gallons) (>55 gallons and<250 gallons) / <br /> Product Type: FOl/./ 2 —C�a..! L <br /> Total Capacity: (( p gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) Containers (2821) #of Containers: ( TA#:115 <br /> (>250 gallons) (>55 gallons and<250 gallons) p <br /> Product Type: r b W�j /L -(u Ac, 0 1—L t <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: OI gallons Total Capacity.for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial t.Q By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />