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SAN JOAQUIN COUNTY <br /> ,.,ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 East Main Street,Stockton,CA 95202-3029 <br /> 60 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM) <br /> Facilityme: Page / Of <br /> U S <br /> Facility Address: NG city: Inspectionpate. <br /> FA M PR#: Program Elemeat: <br /> /� l 6 p " 3 2 8 S'® <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product <br /> Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) n <br /> 1 Product Type: a4 0 j <br /> Total Capacity: 3 O o 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 /> 2 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: TAR: <br /> (>250 gallons) (>55 gallons and Q50 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 (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 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 Q50 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: 3 00 —;aIIonsj Total Capacity for Site: Od gallons <br /> Comments: <br /> EHD Inspector. A Reviewed Date: Entered Dat <br /> By Initial: By Initial:VAJ <br /> /� D <br /> EHD 2"l C— l <br /> 0(/16/08 <br />