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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMET <br /> 600 East Main Street, Stockton,CA 95202-304, <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 /> 'Has Page of <br /> 04 A -,01 <br /> Facility ddress: City: Inspect' n Da <br /> 2 D 65 Z,,Z <br /> FA#: PR#: Program Element: <br /> asp 93 /W6JZ3 �Z D z83 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground 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 /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: ©6/ <br /> (>250 gallons) (>55 gallons and<250 gallons) !� - Q <br /> 1 Product Type: �/�,/�%,t <br /> Total Capacity: /0 OGO gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TAM 0-:57&,3[g 1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: SUU gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ontainers (2821) #of Containers: _� TA#: 3(Qo2 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: Z )r0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) eContainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: / C � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: �_ TA#: 6C2y <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 s Product Type: � <br /> Total Capacity: v5, gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: d Z O gallons Total Capacity for Site: gallons <br /> Comments: <br /> �w ��' �A S 1' o f � �a �If �✓ <br /> EHD Inspector: 1 Reviewed Date: Entered Date: <br /> By Initial: �� �, ��� By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />