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SAN JOAQUIN COUNTY <br /> �../ENvIRONMENTAL HEALTH DEPARTMEN' <br /> 600 East Main Street,Stockton,CA 95202-302 <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 /> L Page of <br /> Facility Address: City: Inspectioz& ,/D� <br /> / 325PL FGIap d / <br /> FA#: y PR#: Program Element: <br /> �D o2 <br /> Tank/Container Information <br /> Complete for Il 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 <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 1 � Product Type: <br /> Total Capacity: 7 � 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 /> 2 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 /> 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 Q50 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 Install Date: <br /> (per tank or cumulative for containers by product type) - <br /> Total Capacity this Page: d gallons Total Capacity for Site: 0 gallons <br /> Comments: <br /> 0-fillaAS <br /> EHD Inspector: Reviewed ( Date: Entered Date: <br /> � By Initial: W(./ �.Z.(p-Q� By Initial: Z <br /> EHD 28-01 <br /> 01/16/08 <br />