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SAN JOAQUIN COUNTY <br /> f ENVIRONMENTAL HEALTH DEPARTMENT <br /> 00 East Main Street, Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: (' Page of Y <br /> VS- 5 `_ C, N tnspe ion Dcl <br /> e: <br /> City: <br /> li[y Address: - Y� 2 r D <br /> SFR#jj,'�'' ,L !] Progra ems nt:. <br /> FA#: J/S7 V/ / 12— <br /> C <br /> C �6 <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) #of Containers: TA#: i9! /Z2E,3 <br /> 1 Product Type: i s�At <br /> (>250 gallons) (>55 gallons and<250 gallons) `� r r <br /> Total Capacity: 15k6f1 gallons Install Date: <br /> (per tank or cumulative for containers by product type) /y <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: /9� Ir7 <br /> (>250 gallons) (>55 gallons and<250 gallons) L <br /> Product Type: /"i.9ST� 4i <br /> 2 Total Capacity: ;7, 0 b C) gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> [�'"Iank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) n <br /> 3 Product Type: <br /> Total Capacity: Ztl-d O gallons Install Date: <br /> (per tank or cumulative for containers by product type) p <br /> P,-fank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) r <br /> 4 Product Type: <br /> Total Capacity: 0 0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> 0_.�rank(2820) ❑ Containers (2821) #of Containers: TA#: 19Jrgl '�� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: ✓v (�'� <br /> Total Capacity: I Dl/ gallons Install Date: <br /> (per tank or cumulative far containers by product type) <br /> g <br /> Total Capacity this Page: <br /> allons Total Capacity for Site: d gallons <br /> Comments: <br /> Reviewed Date: Entered Date: <br /> EHD Inspector: y <br /> B Initial: ,,R-�� B Nitial: f( O <br /> y <br /> EHD 28-01 <br /> 01/16/08 <br />