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SAN JOAQUIN COUNTY <br /> INVIRONMENTAL HEALTH DEPARTMENT <br /> .,JO 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 of <br /> G D 1 <br /> Facility Address: City: Inspectio Dat <br /> 3 V-S-v A v o O'GA zA T>2 g> - U <br /> FA#: PR#: Program Element: <br /> j2-� 6Y 1 OA_a3 Z <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 /> E&- ank(2820) ❑ Containers (2821) #of Containers: TA#: D S"!(o <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> Total Capacity: 'L12 0 gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: - TA#: �ao� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: Q � <br /> Total Capacity: d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) E-1 Containers (2821) #of Containers: TA#: dV� <br /> (>250 gallons) ailon-and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: _ J.�0(3___gallons <br /> (per tank or cumulative ntain oy 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: a gallons Total Capacity for Si` 9 gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: fw� C6. By Initial: <br /> EHD 28-01 �l <br /> 01/16/08 <br />