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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> X600 East Main Street,Stockton,CA 95202-31� <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: Page of <br /> lQ Z n <br /> Fadlity Address: City: Inspectin Z 3 G U <br /> '1 D n Prog�Elemegti <br /> FAM 135 S PR : <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 /> ank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) 6 <br /> 1 Product Type: <br /> Total Capacity: 3 S b gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative fm containers by product type) <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TAM <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: 3 SQ gallons Total Capacity for Site: gallons <br /> Comments: <br /> �32-3 6 -/ lam <br /> EHD Inspector: Reviewed Date- Entered Date: <br /> By Initial: "l'�0' By Initial: Z <br /> EHD 28-01 ll�� <br /> 01/16/08 <br />