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SAN JOAQUIN COUNTY <br /> ;NVIRONMENTAL HEALTH DEPARTMEN' <br /> vt)0 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: Page Y of <br /> Facility Address: City: InspectD e: <br /> i <br /> () vy <br /> FA#: PR#: Prograni 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 /> ank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: �P <br /> Total Capacity: -a-5 ,06) a' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El,,'�ank (2820) ❑ Containers (2821) #of Containers: TA#: 12`51 <br /> 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) 2ZZ�r <br /> Product Type: <br /> Total Capacity: Z rad �4 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 /> 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 /> (>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 p 6 gallons Total Capacity for Site: S Z U gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: /_41 <br /> EHD 28-01 <br /> 01/16/08 <br />