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SAN JOAQUIN COUNTY <br /> y/ ENVIRONMENTAL HEALTH DEPARTMET%.,# <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 /> Facirkme: <br /> Q 8 T � A Page—L—of <br /> Facility Address: City: Inspection D e: <br /> 36 1- iz o$ <br /> FA#: PR#• Program E emea <br /> ©5a oaa z $ <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 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 /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: 6:-A <br /> Total Capacity: 9 O a gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers dT�Y• <br /> 2 Product T <br /> (>250 gallons) (>55 gallons and<250 gallons) Type: /✓4t4 C l � <br /> Total Capacity: r, o O 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<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: 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<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: 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<250 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: / 000 gallons Total Capacity for Site: 0 Q gallons <br /> Comments: 1 <br /> EHD Inspector: Reviewed Date: ,/ Entered Date: <br /> By Initial: Wi 1}�1j•O By Initial: I <br /> EHD 28-01 <br /> 01/16/08 <br />