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SAN JOAQUIN COUNTY <br /> " " "1✓'�NVIRONMENTAL HEALTH DIPARTM'. +' <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 /> �li —LC Page 'of <br /> Facility Address: City: <br /> Inspection Date: l <br /> a FA#: PR#: i <br /> a <br /> Program Element: <br />_ it <br /> Tank/Container Information <br /> Complete for all sites with cu ative �10und storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons.m ete onr each tank or each cumulative container product type. <br /> ❑ Tank(2820) Containers (282 ) #o f Containers: TA#: <br /> (>250 gallons) (>55 g and<250 gall s) - <br /> 1 Product Type: <br /> tr <br /> al Capacity: A41 Z gallons <br /> tank or cumulative for containers by product type} Install Dater <br /> ❑ Tank(2820) El Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 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 /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date. <br /> a <br /> ❑ Tank(2820) ❑ Containers (2821) '#of Containers: TAM <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: ' TAM <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: -i/ gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: fi ,ktv By Initial: kv 5/1 <br /> EHD 28-01 <br /> 01/16/08 <br />