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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMI <br /> 100 East Main Street,Stockton,CA 95202-3u2o <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> /G n/ V Page Z of <br /> Ma3a/�ty Address: City: /I� Ins�J( I ;;;Date d` / <br /> FA#: PRM: Program Element: <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: TA#: _ 05/4 -13 o <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: 4ptsrx --Of <br /> L <br /> Total Capacity: ?-&B 3( fl gallons U 44--cl <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers(2821) #of Containers: TA#: ( to 7-3 f <br /> (>250 gallons) (>55 gallons and<250 gallons) ` <br /> 2 Product Type: J�� 6 <br /> Total Capacity: 3-y$3/Dgallons C!5 e <br /> (pr tank or cumulative for containers by product type) Install Date: <br /> WeTank(2820) ❑ Containers (2821) #of Containers: TAM /2-73,2- <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 O Product Type: ( o c <br /> Total Capacity: W-19`31 gallons USe <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers(2821) #of Containers: TA#: — O <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: A /JCA.L Z <br /> Total Capacity: 10400 gallons <br /> (per tank or cumulative for containers b s a Date: <br /> 91 <br /> Tank(2820) ElContainers (2821) #of Containers: TA#: 73 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: �'e,4 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 2 gallons I Total Capacity for Site: 4(a2 CD gallons <br /> Comments: <br /> # 2 3 6Yl�f C <br /> 42Z21 �i2�2u d <br /> iS A/07— e <br /> EHD Insp Reviewed DateIq- <br /> : Entered Date: <br /> By Initial: 11 By Initial: <br /> EHD2"I <br /> 01/16/08 <br />