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SAN JOAQUIN COUNTY <br /> WIRONMENTAL 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: ei--P <br /> `/// Page of-1 <br /> Facility Address: Ci Inspectio ate: <br /> 2- 3 3`^0� /-- A s J n� JV 1. �r6� <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 /> Complete one box for each tank or each cumulative container product type. <br /> ❑ Tank (2820) Containers (282 1) #of Containers: y TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: y PK D4 -/ C�- O <br /> Total Capacity: // y gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) P Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) el- <br /> 2 _ Product Type: �//�?� � � j <br /> Total Capacity: j— gallons <br /> (per tank or cumulative for containers by product type) Install Date: F11/141 <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <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 /> ❑ 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: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> -T By Initial: By Initial: � n <br /> EHD 28-01 <br /> 01/16/08 <br />