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SAN JOAQUIN COUNTY <br />"NVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name: <br />Page � of i <br />a � Cif/� <br />[ <br />Facility Address: <br />citr. <br />Inspection Date: <br />FA #: / � O O O <br />PR #: <br />Program menta <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground <br />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 />ank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: e2,5'`'�,�2?� <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: t�/ly <br />.f %' O � G <br />Total Capacity: o gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) Containers (2821) <br />#of Containers: 3 <br />TAM eQ6 O <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: 11-7 d <br />j'q <br />Total Capacity: � �gallons <br />,� <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) kContainers (2821) <br />#of Containers: / <br />TA#: <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: A) <br />Total Capacity: rs gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) WContainers (2821) <br />#of Containers: <br />TA#: 9,61` <br />4Product <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Type: <br />��)�d72 l/ <br />Total Capacity: 13' gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />ank 2820 ❑ Contain s 821 <br />1 5) <br />(>250 gallons) (>55 gallons and 11, <br />5 <br />Total Capacity: �o O�_ .,..rgalion" <br />@Ylt1C�t <br />�'� <br />sInsfiall Da : <br />(per tank or cumulative for.containers by product type) <br />Total Capacity this Page: 2 <br />gallons <br />Total Capacity for Site: 2 gallons <br />Comments: <br />d V <br />i <br />U <br />to <br />EHD Inspector: <br />el! <br />Reviewed Date: <br />By Initial: /� OI <br />Entered Date/y <br />By Initial '1 / <br />EHD 28-01 <br />01/16/08 <br />