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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL 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 /> Facility A dr ss: Cit : Ins ectio ate: <br /> FA#: PR#: 7z"a <br /> D Sas <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in/tasnd containers over 55 gallons. <br /> Com lete one box for each tank or each cumulative container prpe. <br /> ❑ Tank(2820) LtOf5ontainers (2821) #of Containers: 1TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 1 Product Type: I �r D/ L/ <br /> Total Capacity: 2 10 gallons � �o <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) 2 Containers (282 1) #of Co rs. ?� TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) —� <br /> 2 Produ e: <br /> Total Capacity: 2 C1 O gallons <br /> (per tank or cumulative for containers by product type) In a . <br /> ❑ Tank (2820) Containers (2821) f Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: 1�/Z,nj �`� Cl/ <br /> Total Capacity: .',5 gallo <br /> (per tank or cumulative for containers by product typr Install Date: <br /> ❑ Tank (2820) C9'Containf <br /> ) #of Containers: 1_ TA#: <br /> (>250 gallons) (>55 gallons an )4 Product Type: ('j/ -- OTotal Capacity: ✓ Js <br /> (per tank or cumulative for containers by pInstall Date: <br /> ❑ Tank(2820)j(>5d <br /> ers (2821) #of Containers: TA#: <br /> (>250 gallons) <250 gallons) <br /> 5 �'roduct Type: <br /> Total Capacity: gallons <br /> (per tank or cumulativproduct type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> 9A r, 0-7 - <br /> l3 � / <br /> EHD I pectora , Reviewed Date: Entered Date <br /> By Initial: Uv' C(., t By Initial: <br /> EHD 28-01 uu <br /> 01/16/08 <br />