Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTIV. <br />600 East Main Street, Stockton, CA 95202-R - <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name: <br />)T f <br />Page of �lc <br />; 11%% !� <br />Facility Ad r ss: City: <br />0 sC� ' �t Z - T r � 'CL �� <br />Inspection te: <br />FA . IF <br />ac�c I�I <br />PR #: <br />e5ag)3 <br />Program Element: <br />2S'�V <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 />❑ Tank (2820) Containers (2821) #of Containers: TA#: <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: S,5gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />(� <br />(>250 (>55 and <250 <br />❑ Tank (2820) EWontainers (2821) #of Containers: % TA40/ <br /> <br /> <br /> CTotal <br />t <br />Capacity: j� gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ <br />Tank (2820) ('Containers (2821) #of Containers: ` ` TAM <br />3Product <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Type: <br /> <br /> <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />P- Tank (2820) El Contain 1) #of Containers: TA 5 (Q 0� <br />4 <br />(>250 gallons) (>55 gallons qd <250 gallons <br />490 Product T <br />Total Capacity: gall. Install <br />(per tank or cumulative for containers by pros e) <br />L,fank (2820) ❑ Contain 21) #of Containers: TA#: <br />5 <br />(>250 gallons) (>55 gallons d <250 gall. s) <br />1000 Product Type: f rC— 0 i <br />Total Capacity: ga /ins <br />Install Date: <br />(per tank or cumulative for containers by pro uct type) <br />Total Capacity this Page:,7� Sq gallons <br />Total Capacity for Site: gallons <br />Comments: g 3 3- 44 11 C <br />On 4 <br />EHD Inspector: ir ` <br />I <br />Reviewed Date: __'' <br />By Initial: U A 1 '�, L 04 <br />Entered Date: <br />By Initial:� C % cf <br />EHD 28-01 <br />01/16/08 <br />J <br />