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SAN JOAQUIN COUNTY `.01 <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: / <br /> -rTw Page -L of <br /> Facility Add City: Inspection te: <br /> FA#: PR k: — Program EI ent: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks'and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> E2/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Product Type: Lrla (� p 7 <br /> Total Capacity: gallons d A� <br /> (per tank or cumulative for containers yproduct type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 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 /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> L <br /> Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 5-0-0gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed ` - wI Date: Entered Date: <br /> �Q By lnkial: VN" By Initial: I O <br /> "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "Container means a storage device designed to be moved when full. <br /> EAST SURVEY FORM <br /> 08/17/081voe <br />