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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENI40 <br /> 1'900 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> t <br /> Page of 3 <br /> Facility Address: <br /> ty° Inspection Date: <br /> FA#: PR#: <br /> rr �a 7� Progra ElemenC <br /> C7 j' <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 roduc e. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1Product Type: <br /> 6(J <br /> Total Capacity: d 0 d9 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: J� ?DD <br /> (>250 gallons) (>55 gallons and<250 gallons) 114 <br /> 2 Product Type: lJ51 <br /> Total Capacity: T d o p gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers2821 <br /> ( ) #of Containers: TA#: rj rj j BBQ <br /> (>250 gallons) (>55 gallons and Q50 gallons) � <br /> 3 Product Type: <br /> Total Capacity: SO 00 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 (>250 gallons) (>55 gallons and<250 gallons) - - <br /> Total Capacity: gallons Product Type: <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 /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers typ <br /> by product e) <br /> Total Capacity this Page: 0 ®� gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector Reviewed Date: Entered Date: <br /> By Initial: By Initial: ' <br /> EHD 28-01 <br /> 01/16/08 <br />