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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME1 <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 /> T C 0 A S T Page '2--- of <br /> Facility Address: City: Ins �t tV l? <br /> FA#: PR#: Program Ellement: <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 /> Complete one box for each tank or each cumulative container product type. <br /> ank(2820) ❑ Containers (2821) #of Containers: TA#: Q5T7 q <br /> (?250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: O z7 gallons <br /> (per tank or cumulative for dontainers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TAM Ile g� <br /> (>250 gallons) (>55 gallons and<250 gallons) / L� <br /> 2 Product Type:(i(/!� S v'!� '2' <br /> Total Capacity: S7& 0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Vllfa�k (2820) ❑ Containers (2821) #of Containers: T MIQ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type:' • <br /> Total Capacity: - <br /> aD p gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> -0t4ank (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: TAM <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: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date <br /> By Initial: By Initial: /„ a <br /> EHD 28-01 �L G <br /> 01/16/08 <br />