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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> o00 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 /> Page of <br /> Facility Address: / City Inspect;vy/"Ts <br /> A S 5 f <br /> FA#: PR#: Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. <br /> Co Tete one box for each tank or each cumulative container product type. '/ <br /> El Tank (2820) Containers (282 1) #of Containers: TA#: 42,.f `1 7T <br /> (>250 gallons) (>55 gallons and<250 gallons) �r <br /> 1 Product Type: A T <br /> Total Capacity: �� gallons T— <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) T 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) 2 Containers (282 1) #of Containers: S TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: � n To 0e, 01 <br /> Total Capacity: 2-115./ gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) Containers (282 1) #of Containers: _ TA#: 067/ 17 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> U <br /> 4 Product Type: �Jf,>fa 0 F <br /> Total Capacity: ?_'L 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: ��/ 71 7� <br /> (>250 gallons) (>55 gallons and<250 gallons) / l <br /> 5 Product Type: �il//aS�� o <br /> Total Capacity: �j�5 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: s' gallons Total Capacity for Site: gallons <br /> Comments: <br /> _T <br /> EHD Inspector: �/� Reviewed Date: Entered Date: <br /> l//✓ By Initial: By Initial: kP <br /> EHD 28-01 <br /> 01/16/08 <br />