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SAN JOAQUIN COUNTY <br /> ,,NVIRONMENTAL HEALTH DEPARTMENT <br /> �0 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: Page Of <br /> Facility Address: <br /> City: P V <br /> 2 �2 N A� /N� /Q� S T0G /G7 6t/ r fytr s <br /> FA A: PR#: PProgram F,leme� <br /> x'70 73 a 2 a, <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 tylye. <br /> Tank(2820) ❑ Containers (2821) #of Containers: -TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) /l <br /> 1 Product Type: <br /> Total Capacity: Z 0 L9 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 /> 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 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 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: 'fA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> $ Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) - -- <br /> Total Capacity this Page. Q gallons Total Capacity for Site: tw gallons <br /> Comments: <br /> EHD Inspector. Reviewed _I Date:\ Entered Date: <br /> <j By Initial: VA ��'2�'w By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />