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- <br /> w EWi6't4MENTAL HEALTH I EPARTM N - <br /> x <br /> `1'600 fast Maiit`.Street,Stvakton,01.95202 029 <br /> ",. <br /> v <br /> Telephone"r.(209).468-3420 Fax {209)"468-'3433 Web wwry sjgay.arg/ehd <br /> AgC VEG1tOUNb PETROLEUM:STORAGE PROGRAM SURVEY FORM' -.' ' <br /> C- 0 Al .Page•of �C <br /> Z. <br /> ff �t�ptio>; ��: <br /> )Facility Addkess: City ✓ <br /> p 6�: <br /> PR W. program'lEleaient: <br /> ... - . <br /> Tank/Cont_ainer Ia ormatiolsl� r vti <br /> Coz tplete for <br /> sit' with"cumul tine abgvegroitnd 5toc'age of pstroleusii Z 1320 gallons>n tanks ani?catttainers aver.55 aflotis <br /> °- - „COM eteon6 box for,each.tank er,each cu�uu alive antainet" roduct <br /> .. <br /> C Tatilr(2820)' ' Containers-(2821.) �� -#a�'C6niAiners: ' TA#:. <br /> x254 grdions) (555 gallons and e250 gailoos) I .. <br /> 1 _ POriuct:Type (J <br /> �Tota1 Capacity: // _dons ",Iii tall°Taste: <br /> (Per Lwk or'cun:ulattve fleece nlataC*s by prodUe t type) <br /> s <br /> CpiltBs leiCS 2$21 f Containers: TA <br /> r <br /> T <br /> ;A <br /> 2820 C ). #o <br /> (520 gallons? , C>SS: Mons uad' 50'galioris);' . <br /> PrO�UCt:T}+pe: <br /> 2,1 Total Capacity.. <br /> ;gallons" <br /> rod e t Ibstall.Date... <br /> (per tank or-cumulative far centaintrs by P y0c)- <br /> 0 Tank{2820)` 0 C6ntaincrs (282'?)" ##of Contain : ... TA#: <br /> (y25(1 gallons) .. (>55':gallonj aid-e25a,g:illons) <br /> ..r. Product Type.. <br /> Tots? Capac ty. :; : gallons install Date <br /> (per tank oreun!utative'f6 co 0Wnetsby'prad40tY"e) P <br /> Cl.,`t'a ik (282t?). Cl.Containers(2'821) ; #af ContainETS: TA#: <br /> _ <br /> 4 ' Pr66ct Type< <br /> Total Capacity dons <br /> a. <br /> (per tank or-cumuiatnic for ctrntaineas by pracluct type). install Date: <br /> 77 <br /> ❑ Tank(2820)' O Containers(282 t)' #cid Containers: `, TA#: <br /> (>250 gallons) . (>55 gallons and<250.ga11ons) <br /> Product I yf3e: <br /> i gallons Total <br /> tank or c+�ttt <br /> Capacity.. <br /> Install.Date: <br /> (, lativc'for containets by;prvclluc t type) <br /> Total Capacity this la!age: r. gallons Tatal.Capaclty fol Site: �, gallQ�is <br /> f . <br /> Cbmments:: : <br /> EIiD lnsptctar. Reviewetf Data: Eatered Date: <br /> $y initial � - '$y initial: . <br /> ' EFIC?28 01 <br /> deur "� <br />