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T <br /> SAN JOAQUIN COUNTY <br /> IkNVIRONMENTAL 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 l <br /> ge � of / <br /> Facility Address ^ City: Inspection Date: <br /> -92M 6575 01976 <br /> FA#: PR#: Progra E ment: <br /> Tank/Container Informatio <br /> Complete fo ll sites with cumulative aboveground storage of petroleum —>13;2 allons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulativeontainer product type. <br /> Tank(2820) ❑ Containers (2821) #of Container : TA#: Q`SiSq'D$ <br /> (>250 gallons) 5 gallons and<250 gallons) " (� <br /> 1 Product T e: �(Q,�''Ca/ <br /> Total Capacity: b U gallons Install D te: <br /> (per tank or cumulative for containers product type) <br /> ❑ Tank(2820) Containers 2821) /Prduct <br /> tainers: Z TA#• /951,5 q <br /> 2 (>250 gallons) (>55 gallons and<250 Ilons) Type: <br /> �e- S <br /> T e: ''1 e <br /> Total Capacity: gallo(per tank or cumulative for containers by product type) Date: <br /> Tank(2820) ❑ Containers (2821) Containers: TA#: 96-15 qj q <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Prodlt Type: L.Ub rijr1 <br /> Total Capacity: gallon Install D e: <br /> (per tank or cumulative for containers by product type) / <br /> ❑ Tank(2820) Containe/(21) #of Containers: ` d TA#: �(>250 gallons) (>5 gallons and< ns) I _Ing4 Product Type: IQ• 1 Total Capacity: ns(per tank or cumulative for containers by proInstall Date: <br /> F6.Tank (2820) ❑ Contai rs (2821) #of Containers: T <br /> (((>250 gallons) (>55 gallons d<250 gallons) <br /> 5 Product Type: <br /> Total Capacity. gallons <br /> Install Date: <br /> (per tank or cumulative for contain s by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: 2 gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: B <br /> EHD 28-01 <br /> 01/16/08 <br />