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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENI,� <br /> - 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: , <br /> Page of <br /> Facility Address: City: Inspection�t: a/ R 3z AVjE o / <br /> FA#: PR#: } Program Element:_ <br /> ��' 961;1$ -7 1 � 5`t <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 /> Complete one box for each tank or each cumulative container product type. <br /> Pe'Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 0250 gallons) (>55 gallons and<250 gallons) <br /> /,, <br /> 1 Product Type: � <,q f'jz 4 /- <br /> Total Capacity: Z S G gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 19 Tank (2820) ❑ Containers (2821) #of Containers: ^TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: //0 D 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: 6 r b gallons Total Capacity for Site: gallons <br /> Comments: <br /> l <br /> EHD Inspector: Reviewed ` Date: / Entered Date: <br /> By Initial: `W,'t,`t1 1, O: By initial: <br /> EHD 28-01 OVV <br /> 01/16/08 <br />