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/ SAN JOAQUIN COUNTY _ <br /> ENVIRONMENTAL HEALTH DEPARTMF <br /> 600 East Main Street, Stockton,CA 95202--.[9 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: ,G <br /> Nl O 1✓ L` U / Fit ►�'J d�� / Au li! Page L of <br /> Facility Address: City: Inspection Date: <br /> FA#: PR#: Program Element: <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 /> Complete one box for each tank or each cumulative container product type <br /> Ell/Tank(2820) -6O'ntainers (282 1) #of Containers: T TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: S S gallons <br /> (per tank r cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: ' T <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 7 ,9,9 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TAM <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<250 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 (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 contains by product type) Install Date: <br /> Total Capacity this Page: / gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: i,� -z4L7 <br /> EHD 28-01 <br /> 01/16/08 <br />