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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMO <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 PROGRAMSURVEY FORM <br /> Facility Name:_rr �� X� / DvQ - G)1n yS�x Page of <br /> Facility Address: G City• Inspec' D e: <br /> z s g <br /> c-A ran/ / b� <br /> FA#: PR#: Program Eleme <br /> pol3s32 1 5"/S719 <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) Containers (2821) #of Containers: A#: /9,,/S$gg <br /> (>250 gallons) (>55 gallons and<250 gallons) Type: <br /> ^� <br /> 1 D T e: / <br /> Total Capacity: 3 ons — <br /> (per tank or c �� comets by product type) Install Date: <br /> ❑ Tank(2820) 03 Containers (2821) amers: _� TA#: D5/5q 13 <br /> (>250 gallons) (>55 gallons and<250 galla <br /> 2 Product Type: 01�' ��� - �y <br /> Total Capacity: gallons <br /> (per u ative for containers by product type) Install Date: <br /> L9'Tank(2820) ❑ Containers (2821) Containers: TA#: $ <br /> (>250 gallons) (>55 gallons and Q50 ga <br /> 3 Product Type: /'1'9 /ted 2 0 G <br /> Total Capacity: gallons <br /> (perf u alive for containers by product type) Install Date: <br /> Ip�lank(2820) ❑ Containers (2821) �µ ontainers: TA#: <br /> (>250 gallons) (>55 gallons and<25 <br /> 4 Product Type: <br /> TotalCapacity: 1 gallons <br /> (per tank or cu ve for contai�ners by product type) Install Date: <br /> ❑ Tank(2820) T1 ontainers (2821) #of ers: TA#: DJ`l!t 7 7 `� <br /> (>250 gallons) (>55 gallons and<250 gallons) r <br /> 5 Product Type: 4 Al l/�� ot 2 <br /> Total Capacity: gallons <br /> (per anve for containers by product type) Install Date: <br /> Total Capacity this Page: Z7j D gallons Total Capacity for Site: Z S gallons <br /> Co ents: <br /> EHD Inspector. Reviewed Date: Entered Date: <br /> By Initial: W� �.lo. By Initial: 0 <br /> EHD 28-01 <br /> 01/16/08 <br />