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SAN JOAQUIN COUNTY <br /> %,o ENVIRONMENTAL HEALTH DEPARTMEN'e`/ <br /> 600 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: <br /> SSG yaL1 (,tio f/TiGIT (,vIL/L/NSoN Page of <br /> Fact' Addres5r City. �RNO q Inspection ate:0S <br /> FA#:I PR#: ' Program a eat: <br /> e� aI O 2, N <1 <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 <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 2�,/ O gallons Mall Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) ❑ Containers(282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: � <br /> Total Capacity: moons 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 Date: <br /> (per tank m cumulative for containers by product type) Install - <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons Mall 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 /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: Zoo gallons Total Capacity for Site: y /Q eali0ns <br /> Comments: <br /> EHD Inspector. Reviewed 1)Ile' Entered Dare: <br /> By Initiate a,1 p By Initial: �( <br /> EHD 28.01 <br /> 0l/16108 <br />