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SAN JOAQUIN COUNTY <br /> ?NVIRONMENTAL 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 Na e• _ <br /> ; C1C �� ,q/A// f pPM S Page of <br /> Facility Address: City: Inspection°Date: <br /> `Z X00 S v 3'f r✓ .l. �/ n/ 1� a <br /> FA#: PR#: ProgramElement: <br /> 93 9 0,5c2V <br /> Tank/Container Information <br /> Complete or 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 /> Tank(2820) ElContainers (2821) #of Containers: ' TA <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: ?- �t <br /> V )gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Me/Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 10 (J i�' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: a�j <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3Product Type: /f,/ 17F p:' <br /> Total Capacity: 5•U�) 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: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: / Reviewed Date: Entered Date: <br /> s.�. <br /> By Initial: V,4J ,a .q•o By Initial: O <br /> EHD 28-01 <br /> 01/16/08 <br />