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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME1 L , <br /> 600 East Main Street, Stockton,CA 95202-3029 <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 /> S 4;- 4 S-PI 7 L. Page / of <br /> Facility Address: Cit Inspecd n te: <br /> � 0 o7' 2 D� <br /> FA#: PR#: Progra lem t: <br /> X000"010 z <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum �t 1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> ED4;nk(2820) ❑ Containers (2821) #of Containers: TA#: e9,1Fj&j "r,) <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: �yA S <br /> Total Capacity: Z Vo b gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ank (2820) ❑ Containers (2821) #of Containers: TAM <br /> ( (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: -�_yy Q 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 /> 3 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<250 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<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: (y Q gallons <br /> Comments: <br /> e <br /> darn S A/21 <br /> EHD Inspector: Reviewed tf, Entered Date: <br /> By Initial: S 7 By Initial: q <br /> EHD 28-01 I <br /> 01/16/08 <br />