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SAN JOAQUIN COUNTY <br /> • :NVIRONMENTAL HEALTH DEPARTMENT <br /> -rO � <br /> 0 East Main Street,Stockton,CA 95202-302Y— <br /> / <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facilit Name: <br /> Rt fiAS Page of <br /> Fachity Add : city: Inspection ate• 1 1 <br /> 13V� N L ii✓F /�� vv, . <br /> FA#: PR#: Program Element: <br /> OS OD7 28 �D <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 /> -- <br /> Complete one box for each tank or each cumulative container product <br /> EP ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 1700 gallons <br /> (per tank or emulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) �n <br /> 2 Product Type: .} <br /> Total Capacity: ZOy 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 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 emulative 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: gallons Total Capacity for Site: gallons <br /> Comments: <br /> l3 G <br /> EHD Inspector: C s Reviewed ' Date: / Entered Date: <br /> By Initial: t/VT1 11_ar)•(� Bylnitial: fG� <br /> EHD 2"1 <br /> 01/16/08 <br />