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SAN JOAQUIN COUNTY <br /> �/'NV IRONMENTAL HEALTH DEPARTMENT <br /> b00 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 /> 7-0 Page / _of <br /> Facility Addr L•—� City: Inspect' Date: <br /> 2/6 6 S 0A-P Alf) QA /r yr <br /> FA#: O 61, PR#: o Progra'Ele?nV- 0 <br /> 8 <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 '-y Product Type: <br /> rL /o <br /> Total Capacity: e1—gallons <br /> (pa/nAk 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: '5 " —gallons <br /> (pa 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 Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA1#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) �r-f) <br /> Total Capacity this Page: gallons Total Capacity for Site: w r� gallons <br /> Comments: <br /> EHD Inspector. Reviewed Date: , / Entered Date: p <br /> By Initial: 11•�- By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />