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SAN JOAQOIN COUNTY ✓�,l 0 <br /> . ENVIRONMENTAL HEALTH DEPAR <br /> 600 East Main Street, Stockton,CA 9520241 <br /> Telepk„ne:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: S Page L_of / <br /> Facility Address: City: Inspeetio Date- <br /> Facility <br /> FA", 06 ✓P To G r✓ S >6 <br /> PER: Progra Eleme t: <br /> S�7 3 <br /> Pooi <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 /> ank(2820) ❑ Containers (2821) #of Containers: TAM a,i'/��j 42 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> I bProduct Type: 7ie� t� <br /> Total Capacity: O (7 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> q Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallotia Total Capacity for Site: gallons <br /> Comments: <br /> aj- to <br /> EHD Inspector: ` Reviewed Date: Entered / n Date: <br /> r By Initial: f-'6'�g By Initiate <br /> EHD 28-01 <br /> 01/16/08 <br />