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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENI1�d <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: Page 7 of <br /> /CY -LG Lo <br /> City: lasp tiogDole: <br /> Facility Adds: /,/// �tL Il e <br /> FA#: PR#: <br /> Z 9 -r, /T L Prore <br /> gm Element: <br /> Z079 <br /> O <br /> Tank/Container Information <br /> Complete for 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 <br /> EP/Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: -Q" <br /> Total Capacity: 500 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 500 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: _ <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: _ <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) /; <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> Ll3a-o <br /> EHD Inspector. Reviewed Date: p Entered Date: <br /> C By Initial: t,'�,pq By Initial: *4 <br /> EHD 28-01 <br /> 01/16/08 <br />