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SAN JOAQUIN COUNTY <br /> • -_ �/NVIRONMENTAL HEALTH DEPARTMENT <br /> b 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: ((�� p <br /> C Z-Z 6 9 vS Page—L of <br /> Facility Address: City: Inspecdo at <br /> oR? tvAy 8714/✓ -1 // 0 <br /> FA#: PR#: Program <br /> Element-. <br /> 50'113�10 ZS VO <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 /> Tank(2820) ❑ Containers(2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: _ <br /> Total Capacity: _�0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Tank(2820) ❑ Containers (2821) #of Containers: T TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) l C tel/F/n <br /> 2 Product Type: ( <br /> Total Capacity: r C 6 allons Install Date: <br /> (per tank or cumulative fo o els by product type) <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TA#: _ <br /> (>250 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 (2821) #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: & oe2 gallons Total Capacity for Site: //00 gallons <br /> Comments: <br /> EHD Inspector. Reviewed Date: / Entered Date/: <br /> -- By Initial: � (,'�.l By Initial: Cl 'dg <br /> EHD2"I CCCIIII"�"" - <br /> 01/l60 <br />