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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTML <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 /> Page of <br /> Facility Address: city. Inspect' D te: <br /> ao C L v /=� �JU� �`� ; <br /> FA#: PR#: Program Element: <br /> 000 D 5-9 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br /> L <br /> Complete one box for each tank or each cumulative container product e. <br /> "T <br /> D ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: /G ° ° O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Ed- ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: /0 G O d gallons 8 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: .TA#: ,1� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 � , Product Type: <br /> Total Capacity: 1 Qs� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Prank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 <br /> (>250 gallons) (>55 gallons and<250 gallons) D� <br /> Product Type: <br /> Total Capacity: !O e)4/U gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 19-'fank(2820) ❑ Containers (2821) #of Containers: T #: a6l62,57� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: la-0 —(gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: S{� C� Q d J gallonsTotal Capacity for Site: (�a -2,(70 gallons <br /> Comments: y <br /> Quo <br /> EHD Inspector: A-z—,,,, 7 <br /> Reviewed Date: / Entered Date: <br /> c . 6 <br /> By Initial: � �' By Initial: <br /> � <br /> EHD 28-01 L <br /> 01/16/08 <br />