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SAN JOAQUIN COUNTY <br /> E-NVIRONMENTAL <br /> HEALTH DEPARTMEi. <br /> j 0 East Main Street,Stockton,CA 95202-3029 <br /> ` Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> IV O, 8 N T8 V 5' S Page-of <br /> Facility Address: City: Inspect' nM— <br /> ?x 50 � - Lauf 5 PV.g �b S-111 <br /> FA#: PR#: Program Element: <br /> n a -2- <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#: D <br /> 50 gallons) (>55 gallons and<250 gallons) y <br /> Product Type: ,b <br /> Total Capacity: % d a ' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> JB¢ ank(2820) El Containers (2821) #of Containers: TA#: l <br /> i G >250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: <br /> Total Capacity: 3�. U gallons <br /> (per tank or cumulative for containers by product type) Install Date: n J <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 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 /> 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 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: o gallons Total Capacity for Site: l,� 3S-0 gallons <br /> Co_ nts: l./t, <br /> O (B / <br /> EHD Inspector: Reviewed ,Da Entered Date: <br /> �' By Initial: By Initial l Ir <br /> EHD 28-01 <br /> 01/16/08 <br />