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` SAN JOAQUIN COUNTY <br /> 0ENvIRONMENTAL HEALTH DEPARTMEN00 East Main Street, Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> S S CC, N " Page I of <br /> Facility Address: City: laspequon D e: <br /> FA p: PR#: �6 ProT nt: <br /> Tank/Container Information <br /> Complete r 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 — <br /> ( ) ( ) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) , I <br /> 1 Product Type: 11s I 1 <br /> Total Capacity: /T� -p <br /> (per tank or cumulative for containers product gallons Install Date: Y <br /> Tank(2820) ❑ Containers (2821) #tof Containers: r.? TA <br /> (>250 gallons) (>55 gallons and Q50 gallons) � <br /> 2 E C)b 0 Product Type: i; � Oi L <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> "(2820)(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<50 gallons) A n�i <br /> 3 Product Type: /J-��' <br /> Total Capacity: IWO O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> P-'Dank(2820) ElContainers (2821) #of Containers: TA#: 1 4eqll <br /> (>250 gallons) (>55 gallons and Q50 gallons) � , <br /> 4 Product Type: <br /> Total Capacity: 0 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [VTank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) ' l/ <br /> 5 Product Type: <br /> Total Capacity: � aD gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: j ganonsj Total Capacity for Site: n gallons <br /> Comments: <br /> it v <br /> 35 740 �50o 1:772 1 <br /> EHD Inspector: Reviewed I Date: Entered te: <br /> By Initial: ,o4 By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />