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SAN JOAQUIN COUNTY _ <br /> _ y l]NviRONMENTALHEALTHDEPAItINIEN <br /> 600 East Main Street,Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www,sjgov.org/ehd <br /> ,r <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: Page—L—of 1 <br /> Facility Address• � City: �- In�Dfttel G TKFA#: , PR#: Pr <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleurn �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) #of Containers:' TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product:Type: <br /> Total Capacity: , ; gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> f �;� <br /> ElFk Tank(2820) C;ontainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and X250 gallons) �- <br />} 2 Product,Type:. : <br /> Total Capacity: Zea gallons Install Date: <br /> (per tank or cumulative for containers:by product type) <br /> ❑ Tank(2820) k"Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 �� Product Type:-.= - 7T-�' O (.,%- <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date' <br /> ❑ Tank(282.0) 0.Containers (2821) #of Containers: TA#: <br /> (>250 gallons) 05 gallons and X250 gallons) <br /> 4 Product Type:.. <br /> Total Capacity: gallons : <br /> Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: ;' . TA#: <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> S Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> :EHD Inspector: Reviewed Date: " Entered Date: <br /> By Initial: ^'_ rr{1 By Initial': g <br /> EHD 2M I <br /> { Ot/16/08 <br />