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SAN JOAQUIN COUNTY <br /> ?NVIRONMENTAL HEALTH DEPARTMEN' <br /> b00 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 /> S -rO C K T D r S �F/: (, � Page of <br /> Facility Address: City: Inspecti n D e• <br /> 3 o 0 3 T k- <br /> FA#: PR#: Program Element: <br /> 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 product type. <br /> Nr'Tank(2820) ❑ Containers (2821) #of Containers: TA#: LQ '? 1 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 10 D 0 C7 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) M,16ontainers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: / 00 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) TT Containers (282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) q <br /> 3 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 /> 4 <br /> (>250 gallons) (>55 gallons and<250 gallons) ���/y O G <br /> Product Type: <br /> Total Capacity: --S gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> a ners 2821 #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: 5d <br /> Total Capacity: J`I gallons hdf t <br /> (per tank or cumulative for containers by product type) Install Date: c <br /> A <br /> Total Capacity this Page: C> gallonsTotal Capacity for Site: gallons <br /> Comment: —70 >t/� <br /> ecto : Reviewed Date: Entered Date: <br /> By Initial: �.�j•a b By Initial: <br /> EHD 28-01 v <br /> 01/16/08 <br />