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SAN JOAQUIN COUNTY <br /> ?NVIRONMENTAL HEALTH DEPARTMENT <br /> -J0 East Main Street, Stockton,CA 95202-3025 <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 /> )q&,y roYorfi Page /_of <br /> Facility Address: City: Inspecti i Date: <br /> FA#: �o PR#: Program le ent: <br /> oai � o zg Q <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 /> Co Tete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 � Product Type: <br /> Total Capacity: 2 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> FI/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) r-- <br /> 2 Product Type: A//j <br /> Total Capacity: D C7 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> LiYfank(2820) ❑ Containers (2821) #of Containers: T,A#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: (y I l� <br /> Total Capacity: r& a 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 /> 4 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<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: O gallons FTotai Capacity for Site: 'Z `jf gallons <br /> Comments: <br /> NJ <br /> -7 <br /> E tor: Reviewed te: Entered Date: <br /> By Initial: By Initial: Q <br /> EHD 28-01 D O <br /> 01/16/08 <br />