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SAN JOAQUIN COUNTY <br /> 'F,,,,NVIRONMENTAL HEALTH DEPARTMENT, <br /> 68 <br /> 600 East Main Street, Stockton,CA 95202-302 f r I <br /> Telephone:(209)4 -3420 Fax:(209)468-3433 Web:wwwsjgov.Orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: - <br /> to T 1O - , ClTy D G IePum ow Page of <br /> Facility Address: "city: N Inspection ate: <br /> FA#: � PR#:© Prog am Eiem t <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 /> Complete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 1/ 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 /> 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 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 X250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and X250 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: U d gallons Total Capacity for Site: Q'a gallons <br /> Comments: Ol� <br /> a <br /> EHD Inspector: Reviewed. Date: Entered Date: <br /> By Initial: 1•�,o� By Initial: L <br /> EHD 28-01 <br /> 01/16/08 <br /> v 'I <br />