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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENJ <br /> `s ( 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 /> U � � Page ! of <br /> Facility Address: y City: Ins n Date <br /> 3 2 oAp W K AVE m-p 2z o$ <br /> FA#: PR Program Element: <br /> 6 - '2- y <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 /> Com tete one box for each tank or each cumulative container product <br /> O Tank(2820) Containers(2821) #of Containers: I TA#: <br /> (>250 gallons) (>55 gallons and 1250 gallons) <br /> I Product Type: 14//4 .r%� 0 t <br /> Total Capacity:gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) 2'6ontainers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 � Product Type: <br /> � /1�I�p JAL /1l <br /> Total Capacity: / gallons Install Date: <br /> (per tank or cumulative for containers by product type) -- - - <br /> ❑ Tank(2820) ❑ Containers (282 1) #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 Q50 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (ptT tank or cumulative for containers by product type) Install Date: - <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TA#: _ <br /> (>250 gallons) (>55 gallons and 1150 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: 3Of gallons Total Capacity for Site: p e� ) allons <br /> Comm <br /> J <br /> J <br /> l <br /> EHD inspector Reviewed 1 Date: Entered te:' <br /> By Initial: �N A.�,1t.0� By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />