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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTNID lie <br /> 600 East Main Street,Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility age Of <br /> Na .r <br /> FacWtyAddress: ' City: �P� Inspectlop stg: O <br /> FA q: 1 OD PR#:EC- G Program6Elle/meUy nt: <br /> / / o zo 1 2-ku a- <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 to one box for each tank or each cumulative container product <br /> ❑ Tank(2820) Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: () / L, <br /> Total Capacity: 2 S O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 91c"ontainers(2821) #of Containers: TA#: <br /> 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: <br /> / (/ <br /> Total Capacity: 2- Ye gallons <br /> (pa 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 /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (pa 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 <br /> (pa tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: _ <br /> Total Capacity: gallons <br /> (pa tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date. <br /> By Initial: By Initial: <br /> EHD 28-0I <br /> 01/16/08 <br />