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SAN JOAQUIN COUNTY <br /> �/NVIRONMENTAL HEALTH DEPARTMENT <br /> b 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 /> flr K CoLV A N AZ-)q//t/9 RANG7't Page of <br /> Facility Address: City: Inspection Date: p <br /> G E S 7-14 // 2 4r'D <br /> FA#: © PR#D�� Program Element- <br /> 1 <br /> Tank/Container Information 9t//-D <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product <br /> Tank(2820) ❑ Containers (2821) ##of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: EO 0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [1/1lin1(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 5-L G h 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 /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (pea 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: , V C gallons I Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector. ,; Reviewed Date: J Entered Date: <br /> By Initial t.att- By Initial: I <br /> EHD 28-01 <br /> 01 W08 <br />