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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> "' 600 East Main Street,Stockton,CA 95202-30r <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 /> t Page Z�— of_3 <br /> Facility Address: City: Inspection Date: <br /> FA#: �1 PR#: �� D Program Element: <br /> D-7OL <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 /> 19"Tank (2820) ❑ Containers (2821) #of Containers: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: I '* o d gallons <br /> (patank or cumulative for containers by product type) Install Date: <br /> 9"Tank(2820) ❑ Containers (2821) #of Containers: TA#: /(o 4NI <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: / d O 04 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Wr 'Tank(2820) ❑ Containers (2821) #of Containers: TA#: 78g0 <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 3 Product Type: <br /> Total Capacity: �O O o o 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<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: UO U gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 9;?1ank(2820) ❑ Containers (2821) #of Containers: TA#: 8 S L Z 9DoZ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 �d4� Product Type: <br /> Total Capacity: 1 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Q O 00 gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date„ <br /> By Initial: By Initial: (OY <br /> EHD 28-01 <br /> 01/16/08 <br />