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SAN JOAQUIN COUNTY <br /> y� ENVIRONMENTAL HEALTH DEPARTMEi,,� <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> G Page Z of 7i <br /> Facility Address: City: Inspection DDar(' <br /> PR#: P • <br /> ✓ vU <br /> FA#: rogram Element: <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 /> Com Tete one box for each tank or each cumulative container product type. <br /> ❑ Tank (2820) kl6ontainers (2821) #of Containers: TAM ,h/JQI'g41 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: 0/ L <br /> Total Capacity: S S gallons -- <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Z'Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: 64 <br /> Total Capacity: / �S gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (2250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <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: TA#: <br /> (>250 gallons) (>55 gallons and<250 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: 7 gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector- Reviewed Date: Entered Date: <br /> By Initial: By Initial: CL! <br /> EHD 2"1 <br /> 01/16(08 <br />