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SAN JOAQUIN COUNTY <br /> �ZNVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029' <br /> Telephone:(209)468-3420 Far: (209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM!SURVEY FORM <br /> Facility Name: _ ,r V 42 ,f�/��/��15 Page of 7/ <br /> Facility Address: ^ /I City: Inspec' nDa�� <br /> 936 >a 'l/ <br /> FA#: Pit#: ProgramElement: <br /> © 3 2 83 � <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 /> Tank (2820) ❑ Containers (2821) #of Containers: t TA#: 01AyWe,�i� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> I Product Type: <br /> Total Capacity: /2 O 0 d gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: /95 &5tQ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: /7- 00& gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> V/Tank (2820) ❑ Containers (2821) #of Containers: _TA#: z57e�T I &t5102— <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> g Product Type: 424 j..,oL <br /> Total Capacity: /20 0 0 gallons Install Date: <br /> (per tank or cumulative for container;by product type) <br /> ark(2820) ❑ Containers (2821) #of Containers: TA <br /> :' ��'j /P 5/9-3 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> q Product Type: <br /> Total Capacity: l 2000 gallons Install Date: <br /> (per tank or cumulative for coon tmnncrs by product type) <br /> ❑ Tank(2820) O'Containers (2821) #of Containers: L d TA#: ze,6-1n:T- <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: /` d 0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: Z 9 D D gallons Total Capacity for Site: J-0 /00 gallons <br /> Comments: �.._ <br /> EHD Inspector. Reviewed Date Entered Date: Q <br /> By Initial: (!✓� �-lo By Initial: ( O <br /> EHD 28-01 <br /> 01/16108 <br />