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SAN JOAQUIN COUNTY <br /> r&VIRONMENTAL HEALTH DEPARTMENT <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: Page/of <br /> a NKt fi- G v?' EsoR r <br /> Facility Address: Ci Inspect.0 Date- <br /> FA 4: <br /> ate:FA#: PR#:af2P;r0 5eptent: <br /> Tank/Container Information 1 <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 M*t type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: OQlp� <br /> 1 <br /> (>250 gallons) (>55 gallons and<50 gallons) Type: n <br /> Product T e: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: �I <br /> 1�4ank(2820) ❑ Containers (2821) ##of Containers: TA#: �?�j Jle,�, 7 <br /> 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) Product Type: 044 r <br /> _ <br /> Total Capacity: 2-00o gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> DiT`ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: S O 6 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ank(2820) 53/containers (2821) #of Containers:A— TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: Q / y <br /> Total Capacity: /.S D 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: 4 6 S 0 gallons I Total Capacity for Site: gallons <br /> Comments: li <br /> �/03 <br /> EHD Inspector: //�� Reviewed Date: q Entered Date: <br /> C.✓ I By Initial: VAd q-,p 6y Initial: 3 DQE <br /> EHD 28-01 c� <br /> 01/16/08 <br />