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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-302Y <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 /> A-fA S T 90 ToC 6 tv /C L« T2A Page—L—of�_ <br /> Facility Address: City: In �irrateis, <br /> Z V-3 S' Lam. G✓1519,t2. A il`^ STS Teo N IQQ_ (7 ��DD/[ 2 <br /> FA#: PR#: Program Element <br /> sS 2- '2-g <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br /> Com Tete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) Containers (2821) #o ontainers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 duct Type: Aa rg JA TF <br /> Total Capacity: gallons <br /> (per tank or cumulative for contain y product type) Install a <br /> ❑ Tank(2820) 2r6ontainers(282 1) #of Containers: TA#: �117310 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: p,� p �`� <br /> Total Capacity: gallons o <br /> (per tank or cumulative for containers y product type) Install Date: <br /> ❑ Tank(2820) P?tontainers(2821) #of Containers: TA#: 1!9 ^1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for contain by product type) Install Date: <br /> Q"Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: -_,r <br /> Total Capacity: G b gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> G7-ofank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 00 Product Type: <br /> Total Capacity: o �O gallons <br /> (per tank or cumulativaoffri containers by product type) Install Date: <br /> Total Capacity this ncPage: gallons Total Capacity for Site: lots" gallons <br /> Comments: <br /> G� Zo <br /> EHD Inspector: Reviewed Date: Entered Date. <br /> By Initial: By Initial: <br /> EHD 28-01 V <br /> 01/16/08 <br />