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SAN JOAQUIN COUNTY <br /> ,,. ENVIRONMENTAL HEALTH DEPARTMENT _ - <br /> '—BW East Main Street,Stockton,CA 95202-302 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name. Page--L of <br /> Faculty Address: //++ �City: <br /> Inspection Date: p� <br /> FA#: PR#: Prograin Element: <br /> FR oo l zz D511�8le23 3 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product <br /> Tank(2820) ❑ Containers(2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) �, <br /> I Product Type: e� <br /> 1 <br /> Total Capacity: 47,S U gallons <br /> (per tank or cumulative for containers by Product type) Install Date: " C`> <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) -- <br /> � 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 Install Date: <br /> (per tank or cumulative for containers by product type) - - - <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<50 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: TAM <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 cSp <br /> gallons Total Capacity for SIte: `aSv gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: f� b <br /> EHD28-01 <br /> 01/16/08 <br />