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SAN JOAQUIN COUNTY' _ <br /> � JJ'NVIRONMENTAL HEALTH DEPARTMENT <br /> CIO East Main Street, Stockton,CA 95202-30294 <br /> Telephone:(209)468-3420 Fax:(209)468-3433.Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> G �� Page •l . ofafi, .. <br /> Facility Address: l? City: Inspection U te: <br /> FA#: r -PR#: Program lem t: <br /> i Tank/Contaimr Information " <br /> Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55.gallons. <br /> i{ Com lete one box for each tank or each cumulative container product e. <br /> tn'Tank('2.' 820). ❑:Containers (282 1) #of Containers: TA#: T� <br /> (>250 gallons) (>55 gallons and<250 gallons) �: <br /> I 1! Product Type: 44. G <br /> Total Capacity: . :1 gallons T <br /> 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 X250 gallons) <br /> 2 Product Type: ;�V_To/L dl U y <br /> Total Capacity: 3 a D gallons Install Date: <br /> (per tank or cumulative for containers by-product type) <br /> fir' ":- <br /> S Tank 2820 ❑ Containers 2821 f <br /> ( ) ( ) #of Containers: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3Product Type: <br /> Total Capacity: 3,tV gallons <br /> (per tank or cumulative for containers by product type) Install Date:. <br /> ld , <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: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> f (per tank or cumulative for containers by product type) Install Date: <br /> e <br /> Total Capacity this Page: Q gallons Total Capacity for Site: ZZ <br /> rgatlons <br /> Comments: <br /> w <br /> EHD Inspector: G Reviewed Date: Entered Date: <br /> By Initial: `0 By Initial: �` <br /> v46 <br /> EHD28-01' <br /> 0I/16/08 � .� <br />