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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL-HEALTH DEPARTM <br /> 600 East Main Street,Stockton,CA 95202-3 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/eYid <br /> ABOVEGROUND PETROLEUM STORAGE.PROGRAM SURVEY FORM <br /> r - <br /> Facility Name: 6 Page `Of !/ <br /> _LC <br /> Facility Address: City: Inspection Date: <br /> FA#: PR#: Program Element: <br /> C Tank/Container Information <br /> Complete for all sites with cu ative ab - ound"storage of petroleum 2,1320 gallons in tanks and containers over 55 gallons. <br /> 06mplete,one box r each tank or each cumulative container pr9duct e. <br /> ❑ Tank 2820 Containers 282 <br /> { ) ( ) #of Containers: . <br /> (>250 gallons) (>55 and<250 gall s) <br /> I� r Product Type: <br /> -,Total Capacity: 40gallons <br /> Ier tank or cumulative for containers by product type) Install Data' <br />} ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and 450 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 450 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<256 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) 4of 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: gallons Total Capacity for Site:. ( � gallons <br /> Comments: <br /> _ !I l( <br /> EHD Inspector:.- Reviewed Date: Entered . Date: <br /> By Initial: ��17 0 By Initial: J� <br /> EHD 2M1 <br /> 01/16/08 <br />