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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN30 East Main Street,`Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax:-(09)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE:PROGRAM SURVEY FORM <br /> Facility Name: T Page of <br /> G Lots Co- <br /> Ci Inspection Date: <br /> Facility Address: City: I <br /> r SD / N <br /> f- ?.FA#: �. PR# Program m <br /> Eleent•2a 6 `Z2.6 �g <br /> l< _ <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br /> Com_ fete one box for each tank or each cumulative container product e. - <br /> r. ❑ Tank (2820) Containers (2821) #of Containers: TA#:, <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> i I Product Type:0 b•/ <br /> Total Capacity: Jr gallons <br /> a (per tank or cumulative for containers by product type) Install Date. <br /> ❑ Tank (2820) containers (2821) #of Containers: / TAMAll <br /> _ '+ <br /> (>250 gallons) (>55 gallons and<250 gallons) ) <br /> 2 r Product Type- �I f <br /> Total Capacity: J 5 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> j <br /> ❑ Tank(2820) ❑ Containers (282 1.) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) 1 <br /> 3 Product Type: <br /> Total Capacity' gallons 1, . ` <br />{ (per tank or cumulative for containers by product type) Install Date: - <br /> �.. <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) 4; <br /> 4 Product Type: <br /> Total Capacity: gallons . <br /> (per tank or cumulative for containers by product type) Install Date' <br /> t ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> i (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons 1= <br /> (per tank or cumulative for containers by product type) Install Date: <br /> { Total Capacity this Page: 77 <br /> gallons Total Capacity for Site: �f gallons <br /> Comments: <br /> 3 zv <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> i By Initial: .a+, el.o� By Initial: Q� <br /> EHD 28-01 <br /> 01/16/08 <br />