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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENT <br /> WO 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 /> Or -1n�r. �. fur-r.>�, -�-1. Cev,-qtr Page - of <br /> Facility Address: City: Inspection Date: <br /> --7 6 s o ':E�' Mc,,,ca g4le- koC '5; 7,-y <br /> zz o <br /> FA#: PR#: Program Element: <br /> PX <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#: T& <br /> _3-/5$6 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: cj(a 0 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 /> 2 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 /> 3 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 /> 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: e -p gallons Total Capacity for Site: $ZOO gallons <br /> Comments: <br /> .�G�IC. C... �1��7 ^4� L•.--Cr ..r S 11 V tr..- T�2i r <br /> EHD Inspector Reviewed Date: Entered Date: <br /> By Initial: By Initial: D8 <br /> EHD 28-01 <br /> 01/16/08 <br />