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SAN JOAQUIN COUNTY <br /> �,r'NVIRONMENTAL HEALTH DEPARTMENT <br /> b00 East Main Street, Stockton,CA 95202-302 <br /> NOW <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> i /df/%�G ,3 KEF •/N�- SSR✓i C' : Page of <br /> Facility Address: City: Inspectio ate: <br /> Ar4 <br /> FA#: PR#: Program Element: <br /> S 20 0 <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 type. <br /> Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: r7i s 8 2 <br /> Total Capacity: 2-50 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<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 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<250 gallons) <br /> 3 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: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: 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<250 gallons) _ <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per rank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 2 0 gallons Total Capacity for Site: 2 6 gallons <br /> Comments: <br /> EHD Inspector. Reviewed Date: Entered Date: <br /> C i Q By Initial: By Initial: / 'Z1 <br /> LfL <br /> EHD 28-01 <br /> 01/16/08 <br />