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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN- <br /> "11600 East Main Street,Stockton,CA 95202-309*' <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 /> 1 <br /> T D T A t T'N1 6Slr (/Ol 2 Page of <br /> Facility.Address: City: las nDaa e <br /> z 1 E6 2- <br /> FA#: PR#: Prvgmm memmt: <br /> ® t L?( &("7 o�a��97 c <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: TA#• <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1Product Type: <br /> Total Capacity: 0 0 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 /> 2 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (pa tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 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: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) _ <br /> Total Capacity this Page: av gallons Total Capacity for Site: ted gallons <br /> Comments: <br /> EHD Inspector: ^ u Reviewed Date: Entered Da i <br /> C•� By Initial: v1 ,"'- <br /> col _p By Initial: <br /> EHD 2"I <br /> 01/16/08 <br />