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SAN JOAQUIN COUNTY Am <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> n <br /> Faciaryeme „I yoI 'Ibi Page 2— Of 'li <br /> Facility Address: , /�.1-l�FN`� \� I City: Inspection Date: <br /> FA q: PR <br /> #: Proggme rL <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 /> r�qq <br /> Complete one box for each tank or each cumulative container product type. <br /> pr Tank(2820) ❑ Containers (2821) #of Containers: TA#: TE QS- 73Z <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: 61 <br /> Total Capacity: ��gallons Install Date: <br /> (per tank or cumulative f r containers byproduct type) <br /> Tank(2820) ❑ Containers (2821) #of Containers: T #: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons Install Date: Ur(cesm ra <br /> (per tank or cumulative for containers byproduct type) <br /> KTank(2820) ❑ Containers (2821) #of Containers: <br /> (>250 gallons) (>55 gal as and<250 gallons) �— <br /> 3 <br /> Total Capacity: _�gallons Product Type: tj <br /> (per tank or cumulative fm containers by product type) Install Date: Ij\L..ID.r'r <br /> ❑ Tank(2820) ❑ Containers (2821) #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 (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: 3 gallons I Total Capacity for Site: V(Jll gallons <br /> Comments: <br /> EHD Inspector: Reviewed Da e Entered Date: <br /> By Initial: By Initial: p /3 <br /> EHD 28-01 0 <br /> 01/16/08 <br />