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SAN JOAQUIN COUNTY <br /> �IWIRONMENTAL HEALTH DEPARTMEN <br /> _A East Main Street,Stockton,CA 95202-302Y <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 /> Facility Address: City: Inspect' n D�t <br /> FA#: PR#: Progr m Element• <br /> /02 <br /> �-- Z � <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 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) ❑ Containers (2821) #of Containers: TA#: d 517?9,,5- <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: 1 0_0—gallons <br /> (per tyk or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM $ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 0-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> I"T (2820) ❑ Containers (2821) #of Containers: 'PA#: j�51 1 773 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: f <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA : 19,J5-1 -7 7 8 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 41- 11Product Type: <br /> Total Capacity: . L't) gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: S�6_1 -7� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: Z 0-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallonsTotal Capacity for Site: -z' 2— W gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: vj� ,,a- lu{ By Initial: X <br /> EHD 28-01 <br /> 01/16/08 <br />