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SAN JOAQUIN COUNTY <br /> /ENVIRONMENTAL HEALTH DEPARTMENT <br /> *K East Main Street,Stockton,CA 95202-3029 <br /> `r Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> I Page of <br /> Facility ddras: City: Inspection D te: <br /> j sTfe— 1 S e <br /> FA#: PR#: Program lement: <br /> 9ss2 2 5 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 /> Complete one box for each tank or each cumulative container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) o , <br /> 1 Product Type: �Qyr'�/ <br /> Total Capacity: / 00& gallons Install Date: <br /> (per tank or cumulative for 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 (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<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: Q (J 19 gallons Total Capacity for Site: /Q Z)Q gallons <br /> Comments: <br /> < 3-2- G� Als <br /> EHD Inspector: Reviewed Date: .utr Entered Date: <br /> By initial (l.�l�� i By Initial: <br /> EHD2"l <br /> 01116/08 <br />