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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEt .,j <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Nam: <br /> e 62 FJ J5 <br /> SERV/Gr Page of <br /> Facility Address: City: Ina Date: <br /> D 1✓L- Tit ; o o p <br /> / FA N: V C)O 6 t L7 T O5 z Program Ekmeat: <br /> T 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 <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> I <br /> (>250 gallons) (>55 gallons and<250 gallons) ProductType: dy V g O �! G o <br /> L—� <br /> Total Capacity: So o gallons <br /> (per tank or cumulative for containers by product type) Install Date: �J <br /> ❑ Tank(2820) 3116ritainers(282 1) #of Containers: v TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> r Product Type: G O O G A/y / <br /> Total Capacity: I gallons <br /> (pr tank or cumulative for containers by product type) Install Date: _ <br /> IR/Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: 0/ /— <br /> Total <br /> /Total Capacity: 27S gallons Install Date: <br /> (per tank or cumulative for containers by product type) — <br /> ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> 3 Zv L <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> �. By Initial: v4j <br /> 5,4,0.Di By Initial: <br /> EHD 2"1 <br /> 01/16/08 <br />