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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL 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 />Page Z of <br />Facility Address:[ <br />Wad <br />Cit <br />Inspection Date: <br />d'q <br />FA #:�� <br />PR #: <br />Program Element: <br />2 76 <br />Tank/Container <br />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 product type. <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: &5-113 63 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />1 <br />Product Type:�/W <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for c ntainers by product type) <br />f4 Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: d <br />Total Capacity: 2sb gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />® Tank (2820) ❑ Containers (282 1) <br />#of Containers: TA#: O5) <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />1 <br />Product Type: �(� <br />Total Capacity: '��M gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />n Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 0,5) <br />�� 7 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />�1'n� <br />4 <br />9agallons <br />Product Type: Lam" <br />Total Capacity: <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) fzd Containers (2821) <br />#of Containers: TA#: <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: r„ <br />Total Capacity: 85- gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: S gallons <br />Total Capacity for Site: <br />gallons <br />Comments: <br />EHD Inspector: <br />Reviewed <br />By Initial: <br />Date: <br />Entered <br />By Initial:6 <br />Date: <br />11 <br />1 <br />EHD 28-01 <br />01/16/08 <br />