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SAN JOAQUIN COUNTY <br /> ZNVIRONMENTAL 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 /> J � Page of 7 <br /> Facility Address: ity: Inspection Date: I� <br /> N . o <br /> FA#: ��� PR#: Program l�nt: <br /> 5— 4--> '571 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1,320 gallons in tanks*and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM �,h a�h�7y <br /> 1 Total Capacity: gallons Product Type: i� <br /> (per tank or cumulative for containers by product type) Install Date: (.f t�Kw 4"'j <br /> ❑ Tank(2820) Q�ontainers(2821) #of Containers: TAM O,5 9-,P47, <br /> 2 r ++ o•� <br /> Total Capacity: bq) gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: U N � <br /> rank(2820) ElContainers (2821) #of Containers: TA#: a5-o',9q 74 <br /> 3 Product Type: <br /> Total Capacity: ab gallons <br /> (per tank or cumulative for dontainers by product type) Install Date: UMV*JIN),� <br /> Tank(2820) Q❑ Containers (2821) #of Containers: TAM 0, <br /> 4 Total Capacity: �! 6M gallons Product Type: i 11, <br /> (per tank or cumulative for coAtainers by product type) Install Date: otv .mw I' <br /> \Dank(2820) El Containers (2821) #of Containers: T TA#: i95�4-7Wb <br /> 5 ((Total Capacity: 2i S-n gallons Product Type: dw <br /> __ <br /> (per tank or cumulative for containers by product type) Install Date: u4t owns <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed 4ga <br /> �1 l Entered Dat <br /> Al- > I By Initial: 2U / Z By Initial: g <br /> *Aboveground storage tank means a tank that has the capacity to store 5ns or more of petroleum. <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 <br />