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SAN JOAQUIN COUNTY <br /> NWRONMENTAL HEALTH DEPARTMErr, <br /> "�40 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 Na <br /> G Page / of / <br /> Facility Address: City: Inspects Date: <br /> 0 4 E 6z k <br /> FA#: 0 PR#: / — Q(j A Program Z D v�t)'D : <br /> r to <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 <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and 250 gallons) <br /> I Product Type: <br /> Total Capacity: gallons Mall 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 /> 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 cumtyp <br /> cumulative for containers by pmdwt e) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and 250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons Mall 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 /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) -- <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: D L OPI(-6/1- A/ V S I I✓if <br /> D <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: V tJ b. 2,+o By Initial: <br /> EHD 28-01 <br /> Ot/16108 <br />