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SAN JOAQUIN COUNTY <br /> SWENVIRONMENTAL HEALTH DEPARTMENT *,00 <br /> ' 600 East Main Street, Stockton, CA 952023029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: r ` �.NIn,,VcC t IIV D Page�_Of <br /> STC v� LlG (Nab vr�Gr�J',/ <br /> Facility Address: City: Inspection te: <br /> %SIG• G✓AY / Z- Lq) AIV-r C'A <br /> FA#: PR#: Program Elerhen <br /> p fL � <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 /> Complete one box for each tank or each cumulative container product type. <br /> 2"T-ank (2820) ❑ Containers (2821) #of Containers: +TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: /f D 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 /> 2 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 /> 3 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 /> 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 this Page. gallons Total Capacity-for Site: gallons <br /> Comments: <br /> El-ID Inspector: Reviewed ` • _� Date: Entered Date: <br /> By Initial: %jVj By lnitial: <br /> EHD 28-01 <br /> 01/16/08 <br />