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SAN JOAQUIN COUNTY <br /> WRONMENTAL HEALTH DEPARTMENT <br /> qw <br /> 0 East Main Street,.Stockton,CA 95202-3029 <br /> Telephone:-(209)468-3420 Fax:.(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Flame• ! <br /> Page of <br /> (53 <br /> Facility Address: City:., Inspecti natep <br /> Z�- S NAV v <br /> FA#: PR#: PragrFm, em <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1320 gallons in tanks and containers over 55 gallons. <br /> Com Tete one box for each tank or each cumulative container product type. <br /> yk <br /> ❑ Tank(2820) . Containers (2821) #of:Containers: ' ' TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Pro4uct Type: <br /> Total Capacity: 2 77 gallons <br /> (per tank or cumulative for containers by product type) lnstall Date: <br /> �r <br /> �1 <br /> Tank(2820) ❑ Containers (2821) #of:Containers: ' TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) d <br /> 2 Product Type: 7f A S R / - <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 /> 3 Product Type: _ <br /> Total Capacity: 6 o -gallons Install Date: <br /> (per tank or cumulative for containers by product type) s <br /> i <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons . ''i - e. <br /> (per tank or cumulative for containers by product type) lnstall 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 E' <br /> (per tank or cumulative for containers by product type) Install Date' <br /> Total Capacity this Page: p $O gallons Total Capacity for Site: gallons <br /> Comments: <br /> E <br /> EHD Inspector: ; .�/f , Keviewed j Data:! Entered Date:_ <br /> Q� By Initial• •`�' By Initial: [¢J <br /> EHD 28-01 <br /> 01/16/08 <br />