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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTME# <br /> 600 East Main Street,Stockton,CA 95202-3 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: O01 V -W Page z— of <br /> Facility Address: � � City: /V, (V/ Inspec' Da[ <br /> FA#: PR"** <br /> 6-1/ Prom E men. <br /> Tank/Container Information <br /> Complete for all sites with cumGlative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> ComVete one box for each tank or each cumulative container product type. <br /> ryUk(2820) ontainers (2821) #of Containers: TA#: <br /> p250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: Z �D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Ei4ark(2820) ❑ Containers (2821) #of Containers: TA#: 05/ (p Lo (oL <br /> (>250 gallons) (>55 gallons and X250 gallons) L <br /> � Product Type: O v <br /> Total Capacity: D d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers(2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 3 Product Type: <br /> Total Capacity: 300 gallons <br /> (per tank or cumulative for container:by product type) Install Date: <br /> ❑ Tank(2820) 016ontainers (2821) #of Containers: A#: (Q <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 r Product Type: <br /> Total Capacity: �j gallons <br /> (per tank or cumulative for containers by product type) Install Date: ,, 1 <br /> ❑ Tank(2820) Containers (2821) #of Containers: 0' TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 d � Product Type: <br /> Total Capacity: � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: I O C)S gallons Total Capacity for Site: 1L gallons <br /> Comments: <br /> EHD Inspc�tor: Reviewed Date: EnteredDa[tj <br /> By Initial: By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />