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SAN JOAQUIN COUNTY <br /> •ENVIRONMENTAL HEALTH DEPARTMENT* <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 /> 61zpc %og S Page 2— of <br /> Facility Address: City: Inspectiu Dat <br /> S Tlc Q�r o� <br /> FA#: PR#: Program Element: <br /> 5 Z J 65a8 83 z 83� <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 /> Copaplete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) VContainers (2821) #of Containers: TA#: Q!�( 7 c&BO <br /> (>250 gallons) (>55 gallons and<250 gallons) ` <br /> 1Product Type: <br /> Total Capacity: .S� 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 /> 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 <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 /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or connotative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 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: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: ,�J Reviewed Date: Entered D3�: <br /> GBy Initial: By Initial: Ul J <br /> EHD28-01 <br /> 01/16/08 <br />