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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEl%we <br /> 1r 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 /> D S GC>I Page of <br /> _L <br /> Fadaty A dress: City: inspectio <br /> A ✓E Q Qa�: o -p <br /> FA k: PR#: Program Element: <br /> � o a 9Sl <br /> Tank/Container Information <br /> ,mplete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> I Co4j <br /> Tete one box for each tank or each cumulative container product <br /> L '9nk(2820) Containers(2921) #of Containers: Tt <br /> (>z 11m) (>55 gallons and-9251 .as) <br /> Product Type: <br /> Total C. ,ity: 50 adllons <br /> (per tank or, 'vive for containers by ,acct type) Install Date: 6 <br /> ❑ Tank(28%20Con ' ers(2821) #of Containers: TAM <br /> (>250 galloon) gano and Q50 gallons) <br /> 2 Product Type: <br /> Total Capacgallons <br /> (per tank or cuma ersby product type) Install Date: <br /> ❑ Tank(2820) C tainers(2821) #of Containers: TAM _ <br /> (>250 gallons) 55 gall and Q50 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative or containers by product type) Install Date: <br /> ❑ Tank (282 ❑ Containers 821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 Ions) <br /> 4 Product Type: <br /> Total Capac' y: gallOnsInstall Date: <br /> (per tank or cu uve for containers by product type) <br /> ❑ Tank 2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gall s) (>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 1 Total Capacity for Site: j o gallons <br /> Comments: L Z �—'q LLD S <br /> /1/14 C i <br /> EHD Inspector: Reviewed , � ^` Datc: Enlered Date: <br /> By Initial: LNv '�,yl- By initiate $ J <br /> EHD 28-01 <br /> 01/16/08 <br />