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_ 'SAN JOAQUIN COUNTY. <br /> �+tENVIRONMENTAL HEALTH DEPARTMEN . <br /> 600 East Main Street,Stockton,CA 95202-3029 ' <br /> Telephone:(209)468-3420 Fax:(209)46.8-3433 Web:www.sjgov.org/ehd. <br />' ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> '—� D ( Page�..of <br /> Facility Address: <br /> ity: o inspection ate: <br /> s -' r <br /> � Ld/ g <br /> Q <br /> FA#: Q / PR#: Program Element: <br /> �![J <br /> f Tank/Container Information ' <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container roduct type, <br /> funk (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: J 00 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 /> 2 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 X250 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: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 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<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: `j p gallons Total Capacity for Site: J`e) 6 gallons <br /> Comments: <br /> -�_ /3 - o�✓f`. <br /> EHD Inspector: �� _� Reviewed Date: Entered Date; <br /> By Initial: $_ -D� By Initial: g <br /> EHD 28-01 v <br /> 01/16/08 <br />