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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMET <br /> 00 East Main Street,Stockton,CA 95202-30L> <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: / �p <br /> VV -5'k' ZIAND Page ✓ of---f� <br /> Facility Address: City: Ins tion ate• <br /> gzg2, �' f/0/� / TAS Arra � ANS� 19 sjiza8 <br /> FA#: PR#: ProgramElement: <br /> 000012-SIE3 2831 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> ank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 P1G✓m C'�W-Lcq Product Type: <br /> Total Capacity: gallons if za t>st 1 Date: <br /> (per tank or cumu ati�f.,.ontainerss by product type) <br /> Tank(2820) ❑ Containers(2821) #of Containers: TA#: 4�2 5:1 w 2©3 <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 2 zlolepD Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 0t <br /> Tank(2820) ❑ Containers(2821) #of Containers: TAM Z2 5j- <br /> 3 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: )?-eo-200 <br /> Total Capacity: ZOUt/ gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 0 Tank(2820) ❑ Containers (2821) #of Containers: TAM O5J l2a'7-95— <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: 2-O Rd gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: y Q 0 gallons <br /> (per tank or cumulative for containers by roduct type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: 2_7 3 Zs— gallons <br /> Comments: <br /> EHD Inspector: Reviewed ` ,, 1 Date: v Entered Dat <br /> C By Initial: ,i2' 8 By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />