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SAN JOAQUIN COUNTY .,I ` ENVIRONMENTAL HEALTH DEPARTMENT T , t s 00 East Main Street, Stockton,04.95202-30� ^} E1 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www,sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY"�FORM Facility Name: Page ' Of Facility Addre�: City: Inspect' Ft i o Z c T STATi or✓.. ,L p FA#: PR#: Progra ea EI mt: ! Tank/Container Information Complete r all sites with cumulative aboveground storage of petroleuin'a 1320 gallons in tanks and containers over 55 gallons. Com fete one box for each tank or eadh cumulative container product e. - Tank(2820) ❑ Containers (2821) #of Containers: :. '.f._-TA#: (>250 gallons) (>5�.gallons and<250 gallons) 1 : . , Product Type: Q � Total Capacity: gallons Install Date: (per tank or cumulative for containers byproduct type) ❑ Tank(2820) ❑ Containers (2821) #of containers: TA#: (>250 gallons) .(>55 gallons and<250 gallons) 2 ' Product Type: Total Capacity: gallons . (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: ' (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons ' (per tank or cumulative for containers by product type) Install Date: . ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons 1' (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) C7 Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product`Type- Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: :`>f'a jj gallons Total Capacity for Sites �� gallons r Comments: '' •� +j E EHD Inspector: �/ Reviewed Date: Entered Date: By Initial:, 1_AJ q 1 5-0i By Initial: YJO t.. w EHD 28-01 . 01/16/08