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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3020 <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 /> A Z-, �-' sT r� r3 L-o (r- / <br /> Facility Address: city• Inspection ate: <br /> f ilii! N F ST f ST gza rl <br /> FA PR#: Progra lem <br /> 93 e 1 7- <br /> Tank/Container <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 <br /> ❑ Tank(2820) TrContainers (2821) #of Containers: T•A#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> I Product Type: �242,wL <br /> Total Capacity: 2-00 gallons <br /> (per tank or cumulative for containcrs by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <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 (282 1) #;o f 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 (2'821) #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 (282 1) #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: 2�p p gallons Total Capacity for Site: gallons <br /> Comments: <br /> 2,61 <br /> EH'D Inspector: / Rcviewed Date- Entered Date: <br /> C� By initial: V d By Initial: slAV V,941,9 <br /> EHD 28-01 <br /> 01116108 <br />