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SAN JOAQUIN COUNTY <br />NVIRONMENTAL HEALTH DEPARTMEN <br />600 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: p D <br />Page _L of <br />Facility Addr s: City: <br />Inspection Qat <br />FA #: <br />(yjL /� <br />PR #: <br />©5.;z <br />m <br />PrograElement: , <br />/ ( L� <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum �* 1320 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#: <br />(>250 gallons) (>55 gallons and <250 gallons) o <br />Product Type: <br />/006 <br />Total Capacity: gallons <br />Install Date' <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) --R�ontain -(2821) #of Containers: -�— TA#: <br />2Product <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Type:._�sj <br />Total Capacity: � gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) Lf"Containers (2821) #of Containers: TA#: , a.D,3l <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: -Zz-o- <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date:Ni�N {wN <br />❑ Tank (2820)Containers (2821) #of Containers: TA#: c <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />r (. CProduct Type: Il -7 <br />Total Capacity: ��- gallons <br />Install Date: :.1 ILiV L <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />(>250 gallons) (>55 gallons and <250 gallons) <br />5 <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: ,/^�� (� gallons <br />I Total Capacity for Site: IAj gallons <br />Comments: <br />2, <br />EHD Inspector: <br />Reviewed Date: <br />By Initial: <br />Entered Dat. <br />By Initial: <br />EHD 28-01 <br />01/16/08 <br />