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- SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> '-&0 East Main Street,Stockton,CA 95202-3020"` <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjg0v.0rg/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: 7 S Page <br /> ARM <br /> FOf <br /> Gv r- oAK <br /> /� City: Inspection [e• <br /> Facility Address: I A p� D I',.— / / 2• "' ? <br /> FA#: CLf PR#: Progmm Element: <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 /> Co Tete 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) —�7—r <br /> PFroduct Type: <br /> Total Capacity: // 0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> 1 <br /> ❑ Tank(2` _, .ontainers (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 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 /> q 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: TAM <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) h <br /> Total Capacity this Page: gallons Total Capacity for Site: / // gallons <br /> Comments: <br /> EHD Inspector.C Reviewed Date: ./ Entered Date: <br /> By Initial: w� i�.q.O T By initial: 102l <br /> EHD 28-01 <br /> 01/16/08 <br />