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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL.HEALTH DEPARTMENT <br /> ""f00 East Main Street,Stockton,CA 95202-302 <br /> Telephone.(209)468-3420 Far.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Nance: f f <br /> � � S T / /�_"/ Page of <br /> Facility Address: City: Inspection Pate: Jl <br /> / 0 A r-- / ?l 6� <br /> FA#: PR#: Program Element: <br /> 02 g o <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product <br /> Tank (2820) ❑ Containers (2821) #cif Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 106 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) El Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Mall 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 <br /> (per tank car c umulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (755 gallons and X250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: - <br /> Total Capacity this Page: gallons IT0Ptal Capacity for Site: J G� gallons <br /> Comments: <br /> EHD inspector: Reviewed Date: Entered Date: <br /> �. By Initial! $,�d.v� By initial: - �l <br /> v <br /> EHD 2"1 <br /> 01/16108 <br />