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SAN JOAQUIN COUNTY <br /> NVIRONMENTALHEALTH DEPARTMEN" <br /> —i00 East Main street,Stockton,CA 95202-3022 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: Page Z of <br /> Inspection Date: <br /> Facility Address: <br /> FA#: PR#: <br /> R0Pro gram Element: D <br /> BTJ Oc•O�G�d- <br /> 51 <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 type. <br /> Z5❑ Tank(2820) Containers (2821) #of Containers: I TAM 26J7 5 z42 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: ��/,�/L' O l t-' <br /> Total Capacity: Z .S o gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2 20) ontainers (2821) #of Containers: TA#: �� '7 ` e <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: rLj d Td}Ti 61 U <br /> Total Capacity: 2,�it) 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 /> 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: 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: 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: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />