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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN-. <br /> 600 East Main Street,Stockton,CA 95202-302 <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 /> Page�of_ <br /> Facility Address: City: Inspec ion ate: <br /> S` W 7� /6 <br /> FA M PR#: Progr o <br /> o/ fzi� 'IU Z�3 <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 prGduct type. <br /> C"fank(2820) ❑ Containers (2821) #of Containers: TA#: nh /7o/`f <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 � Product Type: <br /> Total Capacity: IAO 6?d U gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Eftank(2820) ❑ Containers (2821) #of Containers: TA#: O/ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: l D l U"Uy 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: 140)O 4 J gallons <br /> (per tank or cumulative for ontain�ers by product type) Install Date: <br /> 5;4ank (2820) ❑ Containers (2821) #of Containers: TA#: ,`i 17 B I `J <br /> (>250 gallons) (>55 gallons and<250 gallons) _ <br /> 4 a oed Product Type: Ll/B/E dte/ <br /> Total Capacity: gallons <br /> (per tank or cumulative for o6mainers by product type) Install Date: <br /> C <br /> �1'Tank(2820) ❑ Containers (2821) #of Containers: TA#: /26/-7D [g <br /> (>250 gallons) (>55 gallons and<250 gallons) Product 5 Product Type: L. l/�6 � <br /> Total Capacity: � gallons <br /> (per tank or cumulative for ntainers by product type) Install Date: <br /> Total Capacity this Page: Doc)Sgallons V nJ� galonsQ <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: —/ <br /> By Initial: '��tr6.9`6 By Initial: O' rI i7X <br /> EHD 28-01 O <br /> 01/16/08 <br />