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SAN JOAQUIN COUNTY <br /> �ENv1RONMENTAL HEALTH DEPARTMEIM <br /> 00 East Main Street,Stockton,CA 95202-3fflW <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web.www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> Page of (/ <br /> Facility Address: S qty: U� � G Inspection pate• ,y <br /> FA#: PR#: .lfnn�� Vl' <br /> 3 �� Program Element: <br /> jr <br /> � 8 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> [Rank(2820) ❑ Containers (2821) #of Containers: TA#: Q <br /> (>250 gallons) (>55 gallons and<250 gallons) — <br /> 1 Product Type: <br /> Total Capacity: 0 �a� gallons <br /> (per tank 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: kQ 6 016 gallons <br /> (pertank or cumulative for containers by product type) Install Date: <br /> 54:,nk(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 (>250 gallons) (>55 gallons and<250 gallons) <br /> Total Capacity: 5 OV gallons Product Type: �. <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: Soo gallons t <br /> (per tank or cumulative for containers by product type) Install Date: Cr=� <br /> ❑ Tank(2820) Containers (2821) #ofContainers: TA#: _e25/ (p7D5 <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: b Z 7 gallons <br /> Comments: <br /> EHD Inspector. Reviewed Dale: Entcrcd <br /> By Initial: V 4_e� By Initial: <br /> EHD 28-0t <br /> 01/16/08 <br />