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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMET <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 /> / 1 A�l►f ,.�/T' Page of <br /> Facility Address: Cit Inspect' n Datr: <br /> // Iq <br /> FA#: PR#: Program Element: <br /> 00 o s/ ��3 Z� � I <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 /> Clank(2820) ❑ Containers (2821) #of Containers: `I'A#• <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: / p d O gallons <br /> (per tank or cumulative for containers by product type) Install Date- <br /> ER'/Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: ,/Q p p gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: Se,�2 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 2/Containers (2821) #of Containers: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: ©/ <br /> Total Capacity: r� 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: 14, gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Z�S r gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: VJj SrLp d(� By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />