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SAN JOAQUIN COUNTY <br /> 'ENVIRONMENTAL 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 e: <br /> �/ p G Page of <br /> Facility ddress: City: InspectionDate: <br /> FA#: PR#: ProgramElem t: <br /> too em 300 z <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 /> 11 Complete one box for each tank or each cumulative container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: 5 o 5-- <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 30 0 © gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) C►r Containers (2821) #of Containers: TA#: a 1 <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: 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: 3 l gallons <br /> Comments: <br /> EHD Inspector. Reviewed Date: Entered Date• <br /> By Initial: �,�_(� By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />