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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN' <br /> o00 East Main Street, Stockton,CA 95202-302 <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 /> o CAL-4); _ Page of 5— <br /> Facility Address: City: Ins*Da�21,�111 <br /> 14/)r/ T1C <br /> FA#: PR#: Program Element: <br /> 055 S-3 a3 1 2 <br /> Tank/Container Information <br /> Complet for all sites with cuqx#tive aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br /> C Tete one box for each tank or each cumulative container product type. <br /> Tank(2820) econtainers, (2821) #of Containers: TA#: 126Z7 I I q <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: -,2, 2 O gallons Install Date: <br /> (per or cumulative for containers by product type) <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 . Product Type: (� � � j ,���' L10 <br /> Total Capacity: Z) 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 /> 3 Product Type: D <br /> Total Capacity: gallons <br /> (per tank or cumulative For containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: �STA#:, �!�'J '�rAo2 <br /> (>250 gallons) (>55 gallons and<250 gallons) r <br /> 4 Product Type: � &I <br /> Total Capacity: `4 O D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: 2 5� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 3cj?�C) gallons I Total Capacity for Site: 9�C// gallons <br /> Comments: <br /> # sAf SO/ <br /> EHD Inspector: I Reviewed Date: 1 ( Entered Date: <br /> f By Initial: Y By Initial: /J <br /> EHD 28-0I O� <br /> 01/16/08 <br />