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uwvtKU111WLINsALHPALIHEIEPAK1MEN7 <br /> ..600 East Main Street,Stockton,CA 95202-302v <br /> Telephone:(209)468-3420 Far. (209)468-3433 Web: www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: /� � <br /> D M 0i A (-n t\/ Ho-TPI-TA Page of <br /> Facility Address: Ci[YoInspec[i nDate•O <br /> S Z- S 2 <br /> FA#: PR#: Program Element: <br /> QoQ Sz6379 83v <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. <br /> Co Tete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) Containers (2821) #of Containers: �� TA#: Z- 3/ <br /> (>250 gallons) (>55 gallons and<250 gallons) —T n, <br /> 1 Product Type: E2_j p4 oQJ <br /> Total Capacity: ( 6 ?_ _gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> P <br /> (>250 gallons) (>55 gallons and<250 gallons) ' D / <br /> 2 � Product Type: .(P/��" <br /> Total Capacity: /0 O c gallons <br /> (per lank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) [!"Containers (282 1) #of Containers: 7' 'TA#• 1p <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: _ / PJ O _gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Q Tank (2820) ❑ Containers (2821) #of Containers: f & !?&0 fit <br /> (>25Q gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: Z:2r 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 Pa / C9 gallons Total Capacity for Site: 4zo gallons <br /> Comments: <br /> EHD Inspector. Reviewed Date: Entered Date: <br /> C` By Initial O By Initial: �( D <br /> EHD 28-01 <br /> 01/16/08 <br />