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SAN JOAQUIN COUNTY <br /> '• INVIRONMENTAL 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 /> R <br /> Facilibr, <br /> Name: p ,�_ <br /> RV / .L' /r,a��'l Page of <br /> Facility Address: City: Inspection Date: <br /> 6 � z r tf� N U M A�r_f j5*GA z <br /> FA#: PR#: Program EI menta <br /> `- o a 5 -77- <br /> Tank/Container <br /> zTank/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 /> Eg/Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) r <br /> 1 Product Type: <br /> Total Capacity: 1 0--0 tgallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [Tank (2820) ❑ Containers (2821) #of Containers: TA#: Olt,e2457 <br /> Zv <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 21 0:: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: &AD 7 7r <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: CV_-R <br /> Total Capacity: 3 C(5 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 Fotal Capacity for Site: `' 6"t") gallons <br /> Comments: <br /> EHD Inspector: n Reviewed Date: Entered Date: <br /> By Initial: .nl•0 By Initial 0� D <br /> EHD 28-01 v� <br /> 01/16/08 <br />