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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <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 /> �" ,""`',. �v�l� � jf� ,j''''f>��,(,• Pae of <br /> Facility Address: _ 1 City: Inspection Date: <br /> I �y U-iy-1G <br /> FA Mn 7� PR#: Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2!1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> C cTank(2820) ❑ Containers (2821) #of Containers: TA#: N 6 Tq� <br /> (>250 gallons) (>55 gallons and 1250 gallons) <br /> 1 Product Type: <br /> Total Capacity. '2CA gallons <br /> (per tank or cumulative for c ntainers by product type) Install Date: <br /> ❑ Tank(2820) containers (2821) #of Containers: TA#: �6_1 q q 71) <br /> (>250 gallons) f>55 gallons and 1250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 1 1 b gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) lontainers (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 Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed \ Date: Entered Date: <br /> By Initial: 1 (p. j�I D By Initial: l!7 D <br /> EHD 28-01 V�1� l D` <br /> 01/16/08 <br />