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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENI <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 /> Page 2--of <br /> Facility Address: City: ��� Inspecti�Date- <br /> 'L 3 0 5 a til �ti d <br /> FA#: PR Program Element: <br /> 1fg D5AS8Q ( 283 <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 (2821) #of Containers: TA#: �t <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Tank(2820) ❑ Containers (2821) #of Containers: l , TA#: D5 `7 1 677 <br /> (>250 gallons) (>55 gallons and<250 gallons) n <br /> 2 Product Type: <br /> <br /> <br /> Ba"T'ank(2820) ❑ Containers (2821) #of Containers: 7 �- TA#: 19 T1 71&3 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: ZeW,! gallons � <br /> " <br /> [d Tank(2820) ❑ Containers (2821) #of Containers: TA#: D5/77 � <br /> (>250 gallons) (>55 gallons and<250 gallons) r <br /> 4 Product Type: <br /> Total Capacity: 3 D" gallons /_� <br /> <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: 17 170 <br /> 5 <br /> (>250 gallons) (>55 gallons and<250 gallons) Type: <br /> r P n <br /> Product T e• J / <br /> Total Capacity: �o z) gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: // Q o(9 gallons FTotal Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: ,p Reviewed Date: Entered Date <br /> (� By Initial: By Initial: D <br /> EHD 28-01 <br /> 01/16/08 <br />