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` - SAN JOAQUIN COUNTY <br /> yrrENViRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: / - <br /> S V Page of <br /> Facility Address: City: C S- /i-'L J Inspection Datye- <br /> 701 ✓ T R 'T // <br /> FA#: / s 5- -2, -3 D 92- PR#: Progrsry eN <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 type. <br /> LK�ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: It Q —gallons <br /> (ped tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1>250 gallons) (>55 gallons and Q50 gallons) <br /> Product Type: <br /> Total Capacity: gallons Mall Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) ❑ Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 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: TAM <br /> (>250 gallons) (>55 gallons and<50 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 Install <br /> (per tank or cumulative for containers by product type) Date: <br /> Total Capacity this Page: J a gallons Total Capacity for Site: ZZ� gallon, <br /> Comments: t <br /> EHD Inspector: ,p Reviewed Date: Entered n Date: <br /> By Initial: l�,•10.08 By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />