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SAN JOAQUIN COUNTY <br /> -, NVIRONMENTAL 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 /> Facilit} Name: �Ta Page -7 of 7 <br /> Facility Address: ��II Ci Inspection Date: <br /> !-Ep 0 -23 12 <br /> FA#: PR#: �� �� Program ement:2��v <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 /> ank(2820) ❑ Containers (2821) #of Containers: TA#: i9s- rL�a <br /> 1 Product Type: _ 6 J <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: UN�cuv ,�ly.J <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: M _gallons Product Type: t� <br /> (per tank or cumulative for c tainers by product type) Install Date: V^ <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <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: � �f gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Dat <br /> By Initial: QJV- I-)I( By Initial: e: <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gall ns 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 />