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SAN JOAQUIN COUNTY <br /> NVIRONMENCAL HEALTH DEPARTMENz�� <br /> Ti00 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROL�EQUQM STORAGE PROGRAM SURVEY FORM <br /> Facility Nab: J � o N 5 ' •/� <br /> l/T Page of <br /> Facility Address: City: Inspection D te: <br /> $" f�vST/N �G CGR �� <br /> FA MPR i PR _ ^ 6 Program <br /> Element: o <br /> qpq <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2t1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> anll(2820) El Containers(2821) #of Containers: TAS: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 1 Product Type: <br /> Total Capacity: 0 n gallons Install Date: <br /> (Per tank or cumulative f wntainers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or emulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and Q50 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: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> q 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 /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> fotaI Capacity this Page: gallons Total Capacity for Site: p gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: kll� 11-61-01( By initial: <br /> EHD 28-01 <br /> 01/16/08 <br />