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SAN JOAQUIN COUNTY <br /> vENVIRONMEN'TAL HEALTH DEPARTMENT t <br /> 600 East Main Street, Stockton,CA 95202-342 "° <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd V <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY,,FORM <br /> Facility Name: ✓ <br /> C,�MMUNtU�L� Page C. of <br /> Facility Address: City: Inspec' n'D e: <br /> ?50 01 G S4U e.n t, � d�[ 9 p� <br /> FA#: Program Eleme t: <br /> L <br /> k L lJ V V PR#� `,3 <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 /> Tank(2820) ❑ Containers ( 1} #of Contai s: TA#: <br /> 50 allons <br /> SS gallons and<L <br /> S ) g 50 gallon <br /> t 1 Product Type: qn L <br /> Total acity: U gallons <br /> (per tank or ulative for contain product type) In 1 Date:• [f <br /> Tank(282 ❑ Containers ( I) #of Contain TA#: <br /> >250 gallons) 5 gallons and<250 gallon <br /> 2 Product Type::. i►�4"�a L <br /> Tota acity: g lons <br /> (per tank or ulative or containers by p t type) InS ate: (713 <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: Q'}'/ZS <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: Qf4> NY 2 e,'L <br /> Total Capacity: 10 0 0 gallons p <br /> 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:' 6 Y 2 S e t.. T—`4> � 6 <br /> Total Capacity: 2S ( gallons <br /> (per tank or cumulative for containers by product type) Install Date: '� V <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 50 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: �l e-t— <br /> Total Capacity: Z S(Uhy gallons Install Date' ZQ� t, <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: p gallons FTotal Capacity for Site: ;�f CJ U" ( D gallons <br /> Comments: n C I, 1 „ - /3 � <br /> V� �/'^��9 �t r'�I ` r Zoo$, <br /> EHD In or: Reviewed Date: Entered Date: <br /> five By Initial: CIO By Initial: <br /> EHD 28-01 <br /> 01/I6/08 <br />