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SAN JOAQUIN COUNTY �r <br /> � E• NVIRONMENTAL HEALTH DEPARTME�`T <br /> =7�0 East Main Street,Stockton,CA 95202-3.02 <br /> Telephone.(209)468-3420 Fax:(209)-468-3433 Web"www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM,- <br /> F <br /> ility Name: €' Page of <br /> T-W � SSA � <br /> City: I<nspecti n76V <br /> te: <br /> ility Address: 1: <br /> 1 3/ 9 r <br /> IF <br /> #: / D <br /> --PB#: Prog am Element: <br /> T. D <br /> Tank/Container Inforination <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br />` <br /> Complete one box for each'tank or each cumulative container roduct t e. <br /> ❑ Tank(2820) C/Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: d <br /> Total Capacity: 4) gallons install Date: . <br /> (per tank or cumulative for containers by product type) <br />�� ❑ Tank (2820) L!'C-ontainers (2821) #of Containers: P <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: - U G <br /> Total Capacity: gallons Iristall Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) Containers.(2821) #of Containers: 1 TA#:' _ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: ` <br /> Total Capacity- S 3 gallons <br /> (per tank occumulative for containers by product type) Install Date: <br /> r <br /> I <br /> Tank-'(2820) ❑ Containers (2821) .#of Containers: TA#: <br /> 3. . 0250 gallons) (>55 gallons and<250 gallons) <br /> UL 4 _;`4, Product Type: jos- =,�< <br /> Total Capacity: _ 3LO6 gallons <br /> (per tank or cumulative ontainers by product type) Install Date: + <br /> s, <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 /> Install Date:' <br /> ;(per tank or cumulative for containers by product type) <br /> Total Capacity this Pagr gallons Total apa jg for Site:. , 3 gallons <br /> Comments: <br /> EHD Inspector: � Reviewed Date: Entered : t'n Date: <br /> L By Initial:: By Initial: <br /> ( EHD 28-01 <br /> O t/16/08 <br />