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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME <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 STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> C(J r S IJ if T <br /> Page of <br /> Facility Address: City: ,/� Insp00111al <br /> te: <br /> 1 -2, (l1� ����&� �' I� <br /> FA#: �` d O PR#�l 6 � g 3 Prog��1:� nt: <br /> V S Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >_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) ❑ Containers (2821) #of Containers: TA#: rj / 4 53 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: 9AT <br /> Total Capacity: gallons <br /> (per tank or cumulative for con iners by product type) Install Date: <br /> L�►VTank (2820) ❑ Containers (2821) #of Containers: TA#: Q5r low' <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: �K'A S <br /> Total Capacity: /P& gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: Bt!jje�Q � <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: G f l,57 <br /> Total Capacity: / 6- 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<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: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity th* _ -'�"� *^���*p' Q gallons <br /> Comments: q 5 a <br /> EHD Inspector: X Reviewed Date: ,/ Entered Date: <br /> By Initial: By Initial: 'rld <br /> EHD 28-01 <br /> 01/16/08 <br />