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SAN.DOAQUIN COUNTY '14 ,�, <br /> � ENVIRONMENTAL HEALTHDEPARTNIENTJ. <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:Nvww.sjgov.orgrehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: Page / of / <br /> r- <br /> Facility Address: City: Inspection D <br /> te: <br /> / O }, <br /> FA#. 1 PRO. Program Element: <br /> 0 65'3 D5a��0 2 ';;�o <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 /> ank (2820) El Containers (2821) #of Containers: .TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 1 �+ Product Type: L/ <br /> CS gallons Install Date: <br /> Total Capacity: ??.S <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA _ <br /> (>250-&orst 1>55 gnLom and<250 gaLcss) <br /> 2 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: TA#: i <br /> (>250 gallons) (>55 gallons and<250 gallons) i <br /> Product Type: <br /> Total Capacity: gallons 11,15tall!, <br /> . Dste: <br /> cook k or cumulative for containers by product type) j <br /> I <br /> T - <br /> ❑ TaPPIC (2820) J Containers {2821) =Cf CGntaL.erS <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> A Product Type: <br /> Y Total Canacit"' gallons iiiSLali 1.1di : <br /> 1 — <br /> (per tau;:or cu±nuiutiee:or containers by product type) <br /> ❑ Tank (2820; Containers (2821) #of Containers: TA#: <br /> l ' <br /> (>250 gallons) >55 231lcns and<250 gallons. - - — <br /> Product Tv e: <br /> ..apa <br /> t <br /> :.or.;r�ieuts: <br /> - -- <br /> 1 <br /> Reviewed Date Entered Da[c <br /> EHD Inspect By Initial. �. 1 Initial' <br /> ` �'t1 B <br /> ERD 23-01 <br /> 011608 <br />