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SAN JOAQUIN COUNTY <br /> `Io NVIRONMENTALHEALTHDEPARTMENT N"Olf <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: <br /> 0 Page of <br /> Facility Address: City: Ins a iop at <br /> FA#: PR#: �/��� Prognm Element: <br /> (lj/ /I'. <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 B5l 1plQI4' <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: Cm AS' <br /> Total Capacity: / Z d� 0 gallons Install Date: <br /> (peri tank or cumulative for containers by product type) <br /> L�/Tank (2820) ❑ Containers (2821) #of Containers: TA#: �S/Le LL 1`1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: G4 S <br /> Total Capacity: 50 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM 05�lele,20 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 a U d 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: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: D� 110 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: Z l C 00 gallons Total Capacity for Site: D gallons <br /> Comments: <br /> EHD Inspector: Reviewed Dale: Entered Date: <br /> By Initial: (tel l-J By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />