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1 t <br /> SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTME10 <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 'L of <br /> Facility Address: U City: Inspection Date: <br /> FA#: PR#: Program Element: <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 /> Com Tete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) Containers (2821) #of Containers: -3 TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> I Product Type: in� <br /> Total Capacity: A& gallons Install Date: <br /> (per tank or cumulative forcontainers by product type) <br /> ❑ Tank(2820) O Containers (2821) #of Containers: Y TA#: f� 7r� / s3 l <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: // 0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) / <br /> El Tank (2820) 91-containers (2821) #of Containers: TA#: l9eh 1 Le �3 _7 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: �izeai 0 � <br /> Total Capacity: 1�4 D gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> q 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#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> g Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: Z gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: '0�/ Entered Date: <br /> By Initial: kj.0 S• �6 By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />