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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENT <br /> ZVGO East Main Street, Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Far.(209)468-3433 Web.www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> O Page--Z—of <br /> Facility Address: <br /> City: Inapectio Da[ <br /> o �rl% . <br /> 2 08 <br /> FA#: R#: Program Element: <br /> / 7i a a-a <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 <br /> ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Total Capacity: 300 gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) // <br /> 2 Product Type: (y� <br /> Total Capacity: A/0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: by gallons Install Date: <br /> (per tank or cumulative for containersm by product type) <br /> ❑ Tank(2820) Containers (2821) #of Contain TA#: i <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: 1 /'L <br /> Total Capacity: J~' S gallons - <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 71sgallons Total Capacity for Site: 71S gallons <br /> Comments: <br /> ERD Inspector: Reviewed Date: Entered Dale: <br /> -� <br /> By Initial: ..rA( t`.�1 t� Ey Initial: (� gt <br /> ERD 28-01 <br /> 01/16/08 <br />