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SAN JOAQUIN COUNTY <br /> ONVIRONMENTAL 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: � Page 2- <br /> �of <br /> Facility Address: city: Inspection Date: <br /> g(7�c3 S . CbzV614A (.moi by) m-27-69 <br /> FA#: PR#: Program Element: <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 /> ❑ Tank(2820) 1�Containers (2821) #of Containers: I TA#: pP�/ '�f <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: is w wk <br /> Total Capacity: 22S 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) q I <br /> 2 Product Type: 8a to �7�✓ of <br /> Total Capacity: 8() gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) X Containers (2821) #of Containers: TA#: Dc57 7/h l0 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: 10 W 30 �,lg� td me 6i <br /> Total Capacity: ��0 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 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 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: �f�S gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Dnte:` <br /> By Initial: By Initial_ <br /> EHD 28-01 O <br /> 01/16/08 <br />