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' SAN JOAQUIN COUNTY <br /> ONVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-302 <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 /> F Page�_of / <br /> Facility Address: <br /> C'tv. r Inspection te: <br /> 3 <br /> FA#: V <br /> `�� Z 0?/ <br /> PR#: ProgramElement:' <br /> ua-7 3 <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 /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: g o <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> I Product Type: D Ot50 f/ <br /> Total Capacity: S�aogallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) 1] Containers(2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: D(r-24 rgg <br /> Total Capacity: o.�o gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> fi� Tank(2820) ❑ Containers (2821) #of Containers: TA#: 1�` <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: 5211 l;n <br /> Total Capacity: oao gallons �—"—�T—E i <br /> (per tank or cumulative for co tamers by product type) Install Date: <br /> V Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: O o0o gallons <br /> (per tank or cumulative for co ers 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: S p gallons Total Capacity for Site: pow gallons <br /> Comments: <br /> EHD Inspector: Reviewed Q Date: Entered Date: <br /> C3 6 <br /> By Initial: 7�] By Initial: d <br /> EHD 28-01 v� O <br /> 01/16/08 <br />