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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEZ <br /> 00 East Main Street,Stockton,CA 95202-302 '' <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 /> Ldv � Pageof <br /> Facility Address: �� � ' D Cit �O� ; In77�7.9 <br /> "1v <br /> FA#: PR#: Prog am Element: <br /> O d O 33 72 � / <br /> Tank/Container Information <br /> Complete f 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 container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM 'v <br /> (>250 gallons) (>55 gallons and<250 gallons) p <br /> 1 Product Type: <br /> Total Capacity: 4 0 b D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) EFContainers (2821) #of Containers: TAM B�j (rte lv D <br /> 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) Z— <br /> Product Type: (tel <br /> Total Capacity: �&S 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: Am (�' / <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: TAM <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: G>L os gallons Total Capacity for Site: 6 gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: UV ,l3 0� By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />