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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMEN' <br /> 0 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 /> l r <br /> f r Page of <br /> Facility Addre-ss: City: Inspection te: <br /> 36sL f , - - - f • <br /> 3 PY. <br /> FA#: PR#: Program Element: <br /> b(0 1 to <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br /> Com to one box for each tank or each cumulative container product type, <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: , <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type- �rM L <br /> Total Capacity: �S 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 X250 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<250 gallons) <br /> 3 - Product Type: <br /> Total Capacity: gallons ; <br /> (per tank or cumulative for containers by product type) Install Date: <br /> - s <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 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 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallonsTotal Capacity for Site: �' gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: 4 <br /> By Initial: rh.'�'�+� By Initial: Q �g <br /> £ <br /> EHD 28-01 <br /> 01/16/08 <br />