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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTME' <br /> 600 East Main Street,Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Far.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: n <br /> Page 7—' of <br /> Facility Address: City: Inspection Date: <br /> FA#: PR Of: L Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2-1320 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: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: z5iaaAV <br /> Total Capacity: 3 0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> El Tank(2820) C$ Containers (2821) #of Containers: TA#: 6`� &26? G <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: ANT/ /`RAE21 G'vf,i7� <br /> Total Capacity: S� 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: " O� <br /> Total Capacity: X41"9 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 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 Q50 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons I Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Da <br /> - By Initial: ('t�4 By Initial: ` /v <br /> EHD 28-01 Cl <br /> 01/16/08 <br />