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PW <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> lljZp <br /> A G 6� Page of <br /> Facility Address: City: Inspection to <br /> FA#: PR#: Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and co 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) (>, gal& "ad-Q50 gallons) <br /> Product Type: <br /> Total Capacity: (' g Ions <br /> (per tank or cumulati a for containers by ro uct typ Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) � /� / <br /> 2 �� Product Type: f� D <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers b type) Install Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55allons d X250 gallons) <br /> 3 Product Type: 4zeA S To <br /> Total Capacity: : d�� gallons .d t-4y <br /> (per tank or cumulativ or containers b roduct type) Install Date: <br /> ❑ Tank (2820) ,Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for contaidm product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <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 /> i <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> ? � LV- <br /> 77 <br /> EHD Inspector: Reviewed Da Entered Date: <br /> By Initial: OAA By Initial: B/3 <br /> EHD 28-01 w ' <br /> 01/16/08 <br />