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SAN'JOAQUIN COUNTY <br /> ysNVIRONMENTAL HEALTH DEPARTMEM? <br /> r _ 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: 1 <br /> �ix4 S d d Page��of <br /> ection Da <br /> Facility Address: � " City: � Ins P <br /> FA#: PR#: 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 /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) F±1 Containers (2$21) ##of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: _/O a O gallons <br /> (per tank or cumulative for containers by product type) :Ilistall Date: " <br /> ❑ Tank(2820) CYContainers (2821) '#ofContainers: l TA#: <br /> (>250 gallons). (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: �,s' gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (282 1) #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 containersby product type) " Install Date: <br /> ,C 0 <br /> ❑ Tank (2820) ❑ Containers (2821) '#of Containers: TA#: 6 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: s <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 X250 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: O S gallons Total Capacity for Site: O � gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> Re Initial: �i �b ¢1 By initial: N f/ q` /7 OV <br /> EHD 28-01 e <br /> 01/16/08 i <br />