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SAN JOAQUIN COUNTY J <br /> ENVIRONMENTAL HEALTH DEPA tTMEN-1' TMs, <br /> 00 East Main Street, Stockton,CA 95202-302 l" <br /> i Telephone:(209)46&3420 Fax.(209)468-3433 Web: www,�jgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> r o G r' V/? Page /" of r <br /> Facility Address: City: Inspeetio Date: <br /> Z/ S 9JFGK�FL5' AVS �AfEGA <br /> FA# PR#:oPro am Elc ent: <br /> � <br /> i7 Z- �g <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 /> Com lete one box for each tank or each cumulative"cor—-"bduct t e. <br /> ❑ Tank (2820) Containers (2821) #of Container'_ A#: <br /> (>250 gallons) �>55 gallons and<250 gallons) <br /> 1 ,L Product Type: <br /> Total Capacity: 2 T gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: t TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 1 // p - Product Type: <br /> Total Capacity: Z� o gallons Install Date: <br /> (per tank or cumulative for containers byproduct type) <br /> ❑ Tank(2820) 2 Containers (2821) #of Containers: TA#: ` <br /> 3' <br /> (>250 gallons) (>55 gallons and X250 gallons) Product Type: ' :A7A <br /> fI'—` <br /> Total Capacity: Z 5�'7> 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 /> 4 Product Type: <br /> Total Capacity: gallons <br /> i^ <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 X250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> " I <br /> I <br /> i <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> i� By Initial: �•��• By Initial: <br /> t ` <br /> EHD 2"1 I <br /> 01/16/08 <br />