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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> X600 East Main Street,Stockton,CA 95202-307, <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility N e: h <br /> (1 g nF �� V0 S S� R DA//� Page-4—of <br /> Facility Address: City: Inspeclio ate- <br /> .2/ 2. ,(,Y <br /> te•2 6 AVa NA '�: sclgto l z6 0 <br /> Fn q: PR#: n Prisgrark Ele <br /> Tank/Container Information <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 /> ank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: •{.��(J <br /> Total Capacity: 3W d gallons <br /> (per tank 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: /r'/9 S 77 <br /> Total Capacity: rs gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative fm 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 Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> CBy Initial: y,5_tfl By Initial: 1/1�1 l� <br /> EHD 28-01 <br /> 01/16/08 <br />