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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALtH DEPARTMENT <br /> 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'8TORAGE PROGRAM SURVEY'FORM <br /> Facility Mame: <br /> Page of <br /> F cl lty res . City: ;' Inspect Date: <br /> FA M, PRMProgram Element: <br /> -Tank/Cont liner Information <br /> Complete for all sites with cumulative aboveground storage of petroleum kj 320'gallons in tanks*and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> ❑ Tank (2820) Ly CZi�rs(2821) #of Container TA#: - z5l -7 <br /> 1 Product Type: 5 <br /> Total Capacity: gallons <br /> (per tank or curnulative for eontainers by product type) Install Date: <br /> D Tank (2820) - G� Containers (2821) #Of Containers: E50 TA#: <br /> 22� <br /> Total Capacity: a �p gallons Product Type: Gr.YI Q�. <br /> (per tank or cumulative for containers by product type) 10.C Cu[Q YZ t <br /> - Install Date: <br /> 19/Tank Q820) ❑ Containers (2820 #0f Containers: _ TAM <br /> 3Product Type: <br /> Rly1�II <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) ln$tall Date: M1 <br /> ❑ Tank 2820 0 Containers 2821 #of Containers:�_ 1'A#:. <br /> ( } ( ) <br /> 4 Product Type: T� k_ .Ori <br /> Total Capacity: `r` 00 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> .❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank orcumulative for containers byproduct type) Install Date: 2[P� <br /> Total Capacity this Page: /Z(v� gallons Total Capacity for Site: gallons <br /> Comments: � - <br /> .The Z.t000 <br /> t <br /> , u 0 e/ <br /> EHD Inspeviewed Q Dale: �h Entered Date: <br /> 1 By initial: rWi- �� VI 8y Initial: / <br /> *Abovegroun ge tank means a at has the capacity to std,e 55 gallons or more of p troleum. <br /> **Container ens a storage device designed to be moved when full. <br /> EHD 28.01 <br /> 09/12/08 As-r SURVEY FORM <br />