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SAN JOAQUIN COUNTY <br /> �WIRONMENTAL HEALTH DEPARTMEN' <br /> L-00 East Main Street,Stockton,CA 95202-30290'v' <br /> Telephone.(209)468-3420 Far:(209)468-3433 Web:www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> 2 LST Page G of <br /> Facility Address: City: / Ins yeti° Da <br /> Ilio ,S, e-NE�o 61j LAI L o 0l $p( l p <br /> FA#; PR#: Program <br /> 0 oof6a.6 8� g g D <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 /> Com tete one box for each tank or each cumulative container product type. <br /> rank(2820) Containers (2821) #of Containers: 1— TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) r O <br /> 1 Product Type: L <br /> Total Capacity: ;-1 ,5�a gallons <br /> (pea tank or cumulative for containers by product type) Install Date: <br /> ElTank(2820) lri�Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: A T <br /> Total Capacity: 116 gallons Install Date: <br /> (--per tank or cumulative for containers by product type) <br /> (4 Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: e4lZq J 1 �Z - <br /> Total Capacity: ,S a' 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 /> 4 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <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: (D gallons Total Capacity for Site: Y6 l) gallons <br /> Comments: - <br /> C 3 � <br /> U s i <br /> EHD Inspector: Reviewed , �a ' Date: --// Entered Date: <br /> By Initial: V11-3 $.S'oS By Initial: <br /> EHD 28-0I v <br /> 01/16/08 <br />