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- SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMEl. <br /> 600 East Main Street,Stockton,CA 95202-304� <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 Z Of <br /> 7��✓ TAS � rr � <br /> Facility Address: City: I Inspection Date: <br /> FA#: PR#: Program 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 /> Complete one box for each tank or each cumulative container product <br /> O Tank Containers (2821) #of Containers: TA#: �2 <br /> (>250 gallons) lion and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: S S g <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers(2821) #of Contain TA# <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: fs 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: -Q <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) 2ontainers (2821) #of Containers: TA#: `� t 6:�5.� (>250 gallons) - (>55 gallons and<250 gallons) <br /> Product Type: n.vr(.- a- b , <br /> Total Capacity: Z�� 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 /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: U gallons I Total Capacity for Site: U gallon, <br /> Comments: <br /> B I( <br /> EHD Inspector: Reviewed Date: / Entered Date: <br /> ","it (( By Initial: � S,y$A'6 By initial: a <br /> EHD 28-01 <br /> 01/16/08 <br />