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► 114, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN7r <br /> � . 600 East Main Street,"Stockton, CA 95202-3029. <br /> Telephone:'(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> t ABOVEGROUND PETROLEUM STORAGE'PROGRAM SURVEY FORM <br /> Facility Name: <br /> L <br /> t ��IM� Page of <br /> ;; . <br /> Facility Address: City: Inspection Date: <br /> FA#: �� PR#: I Program Eleme <br /> ?�✓4 <br /> '. Tank/Container Information <br /> Complete for all sites wi6cumulative aboveground storage ofpetroleum z I320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative containerproduct e: <br /> ❑ Tank (2820)" Containers (2821) #of.Containers: � TA#:"" <br /> (>250 gallons) 1551 gallons and<250 gallons) 1_ <br /> 1 Product Type: . ." Sar►r <br /> N �► <br /> Total Capacity: j gallons f- w <br /> (per tank or cumulative For containers by product type) Install Date: <br /> ElTank(2820) N7Containers (282 1) " #of Containers: TAM <br /> (>250 gallons) (;�55.gallons and<250 gallons) `- <br />- 2 Product Type: .Cp,� l V . <br /> Total Capacity: _ gallons L' F <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 ; ' <br /> � ) ( ) � '#of Containers: - TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> T ' <br /> ❑ Tank (2820) ❑ Containers (2821) '#of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) . <br /> 5 Product Type: <br /> Total Capacity: gallons . i, <br /> (per tank or cumulative for containers by product type) Install Date- <br /> Total Capacity this Page: gallons Notal Capacity for Site: {U : gallons <br /> Comments: <br /> 4 <br /> EHD Inspector: Reviewed Date: tebed Date: N <br /> r By Initial: `' 3 �(� y Initial: I� 3 11 F? <br /> EHD 2M <br /> 01/16/08 :i' <br />