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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEI <br /> x 600 East Main Street, Stockton,CA 95202-34' " <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 <br /> Facility Address: -`y City: lnspecti D e: <br /> FA#: Prog <br /> #:PR ram Element: <br /> r�6�a z� s�6 9 �" <br /> Tank/Container Information <br /> Complete fo 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 /> Yank(2820) ❑ Containers (2821) #of Containers: TA#. <br /> ,2gallons) (755 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: Z o b gallons <br /> (per tank or cumulative for containers by product type) Install Date- <br /> "Ta (2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) 1 <br /> 2Product Type: A <br /> Total Capacity: S'n gallons <br /> (per tank or cumulative for containers by product type) Install Date: 4 �1 <br /> wL <br /> IV/Tank (2820) ❑-Containers (2821) #of Containers: -TA#: © 1<!v <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: W/Q �1'�C C (/ <br /> Total Capacity: 9,1T0 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 450 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for coma y 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 Install Date:, <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: I ` N V gallons Total Capacity for Site: I a o gallons <br /> Comments: M9A VY 9&L <br /> LAN <br /> EHD Inspector: Reviewed Date:' Entered Z Date: <br /> y By Initial: ` �$ By-Initial: �7 <br /> EHD 28-01 !/ <br /> 01/16/08 <br />