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SAN JOAQUIN COUNTY <br /> • . ENVIRONMENTAL HEALTH DEPARTMENT <br /> `e00 East Main Street,Stockton,CA 95202-3020" <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 /> D Page of f _ <br /> Facility Addrem: City: Inspection Date: clj <br /> EG popROO ST G ;�; /,,n-;� ,o "fir' : 9 ' " 0 <br /> FA a: Fall. Program Element: <br /> B 2 - <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 /> 041�ank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) - <br /> 1 Product Type: PXJL-)'�1 <br /> Total Capacity: / -I- PQ gallons Install Date: <br /> (Per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 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(2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative fm containers by product type) <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 or cumulative fm 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: OD gallons I Total Capacity for Site: / ZO�� gallons <br /> Comments: <br /> EHD lnspltt Revta tamed / Date-itial: .(v.!)b EntBy ered Dat <br /> EHD 28-01 V iV. w'I <br /> 01/16/08 <br />