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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTHDEPARTMEl' <br /> 600 East Main Street,Stockton,CA 95202-30.zv' <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> FacilityName: <br /> Page / of <br /> FacWty Address: City: <br /> _ Inspection Date: <br /> FA#: N ! I <br /> U 0 D 6 Y /o�✓ PR#: Program Ele ent: <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 /> ❑ Tank(2820) OeContainers (2821) #of Containers: / TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: lJtp�Ql! � <br /> Total Capacity: 2 cSD gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> IP/Tank (2820) ❑ Containers (2821) #of Containers: TAM (9,514.26-�' <br /> (>250 gallops) (>55 gallons and<250 gallons) <br /> ' 2 Product Type: <br /> Total Capacity: /0 U U 8 gallons <br /> (per tank or cumulative for cor <br /> tta�a�.—m by product type) Install Date: <br /> ❑ Tank(2820) 2 Containers (282 1) #of Containers: / TAM <br /> (>250 gallons) (>55 gallons and<50 gallons)3 Product Type: C2 5- 40 W/ <br /> Total Capacity: Z9 r gallons Install Date: moj4em- 4 <br /> (per tank or cumulative for containers byproduct type) <br /> ❑ Tank(2820) G16ontainers (2821) #of Containers:/3 TA#: 1p x262 <br /> (>250 gallong) (>55 gallons and<50 gallons) <br /> 4 gs Product Type: <br /> Total Capacity: gallons p�� pt�P,(ggy <br /> Install Date: <br /> (per tank or cumulative for containers byproductt type) <br /> ❑ Tank(2820) EI-Containers (2821) #of Containers TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 5 Product Type. i /evwt9l ES�fiI t9�I ✓ <br /> Total Capacity: gallons (DCei :vtnati�l2rnH� <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: t7 gallons I Total Capacity for Site: 7/13 gallons <br /> o ents: <br /> EHD Inspector. Reviewed Date: Entered Datle� / <br /> 0 Ey Initial: (I) By Initial: <br /> EHD2MI <br /> 01/16/08 <br />