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_ SAN JOAQUIN COUNTY <br /> t NVIRONMENTAL HEALTH DEPARTMENT <br /> Y 0 East Main Street;-Stockton,'CA 95202-30 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd , <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: j <br /> Page of <br /> Facility Address: ' 7city..A Inspectio Date- <br /> i• FA#: PR#: Program Elemen. <br /> Tank/Container Information <br /> Comple a fo all sites with cumula ' e aboveground storage of petroleum'z 1320 gallons in tanks and containers over 55 gallons. <br /> Com ete one box for each tank or each cumulative container product type. <br /> nk{2820) Containers (2821) #of Containers: A#: <br /> >250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product-Type: <br /> Total Capacity: /3 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <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 /> { ElTank (2820) ElContainers (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 X250 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 (282 1) #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 Foal Capacity for Site: gallons <br /> Comments: <br /> Z 0_0 G 1 <br /> EHD Inspector: ' Reviewed Date: Entered Date: . <br /> By Initial: � /) By Initial: <br /> EHD 28-01 I <br /> ' 01/16/08 <br /> t <br />