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SAN JOAQUIN COUNTY <br /> ,ENVIRONMENTAL HEALTH DEPARTMENO <br /> 600 East Main Street, Stockton,CA 95202-3029 <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 /> Page 2— of <br /> Facility Address City: Inspect n Da <br /> 45 210M41 <br /> FA#: PR#: Program ement: <br /> —7/a t_3 0? <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 /> Complete one box for each tank or each cumulative container product type. <br /> Eklank(2820) ❑ Containers (2821) #of Containers: TA#: Q <j f 7/,7 S' <br /> (>250 gallons) (>55 gallons and<250 gallons) y <br /> 1 Product Type: <br /> Total Capacity: --,L/—(L�-�j�a gallons <br /> (per tank or cumulativeor containers iners 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 (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 for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) ##of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Datc: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspec Reviewed Date: Entered Date: <br /> � <br /> !� By Initial: By Initial: Q' <br /> EHD 28-01 !J <br /> 01/16/08 <br />