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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> "'K00 East Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> KeA �E SO PJ /V C% Page�_of <br /> • <br /> Faci ty Address: City: Inspection gt p <br /> 5 16 S I LT ES CA Lo fV6 <br /> FA#: PR#: Program Element- <br /> 350 D 3 2g <br /> Tank/Container Information <br /> Complete f 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 /> V/fank(2820) ❑ Containers(2821) #of Containers: TA#- <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> l Product Type: <br /> Total Capacity: 1.; &40 gallons Install Date: <br /> (Per tank or cumulative fm containers by product type) <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TAM <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: 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: TAM <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 Install Date: <br /> (per tank or cumulative for containers by product type) -- <br /> Total Capacity this Page: B{7 gallons Total Capacity for Site: Q gallons <br /> Comments: <br /> A <br /> EHD Inspector. \ Reviewed Date: Entered Date: <br /> By Initial: e , By Ineial: /! p <br /> EHD 28-01 <br /> 01/16/08 <br />