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SAN JOAQUIN COUNTY <br /> OWNVIRONMENTAL HEALTH DEPARTME� <br /> 0 East Main Street, Stockton,CA 95202-3 <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 /> Cd A AD Page '� of _ <br /> Facility Address: City: Inspection Date: <br /> FA#: PR#: Program Element: <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 /> Com Tete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: -2 <br /> v <br /> (>250 gallons) (>55 gallons and<250 gallons) O til <br /> (//O/ <br /> I Product Type: / <br /> Total Capacity: S J— gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank(2820) Itd"Containers (2821) #of Containers: TA#: Qhr )(O�o`ZD <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: cJ/Jl✓ O / L./ <br /> Total Capacity: _gallons <br /> (per tank or cumulative for contamers by product type) Install Date: <br /> ❑ Tank(2820) Containers(2821) #of Containers: / TA#: �l<j /IPoZ 02 <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 3 Product Type: �1 ir�F �=1 U/D , <br /> Total Capacity: f'-r gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) M Containers (2821) #of Containers: TA#: 110 z?-:2, <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: c <br /> Total Capacity: J-�r gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) Containers(2821) #of Containers: _ TA#: P5 (r a <br /> (>250 gallons) (>55 gallons and X250 gallons) t,� <br /> 5 Product Type: 12 TW A! f/ <br /> Total Capacity: Tf gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: ?j? gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed 'N-1 Date: Entered Date: <br /> By Initial: V � By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />