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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEI` <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 /> Page of <br /> A G � <br /> Facility Address: City: Inspection to <br /> 2—o • G TO' y rG 0 � <br /> FA#: PR#: ^^ Program Element: <br /> B (:2 (3 && <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 /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) ' <br /> 1 Product Type: /-�Y1'irj G/C a r �✓ <br /> Total Capacity: d� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 19/oTank (2820) ❑ Containers (2821) #of Containers: TA#: ? <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 0 Product Type: 4 L <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> EO'Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: �;e 6? 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 /> 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 FTotal Capacity for Site: gallons <br /> Comments: <br /> Qti7"/ �E2 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> Vo' <br /> f By Initial: O,q_ By Initial: py <br /> EHD 28-01 w <br /> 01/16/08 <br />