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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEW <br /> `600 East Main Street,Stockton,CA 95202-302 <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 /> N l Z0 N ' IV C LF M F L L S/ Page L of / <br /> Facility Address: City: Inspecno Date-, <br /> ( ����f L <br /> FA q: PR#: Progrint Ele nt: <br /> l0 DS�s 93 / <br /> Tank/Container Information <br /> Complete r 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 /> I r, 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<250 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: TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 3 Product Type: <br /> Total Capacity: 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 /> 4 Product Type: <br /> Total Capacity: 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 /> $ Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) - <br /> Total Capacity this Page: gallons FTotal Capacity for Site: "allows <br /> Comments: /9 <br /> v <br /> EHD Inspector. Reviewed Date: Entered Dat p <br /> By Initial: O','yta-�� By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />