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SAN JOAQUIN COUN'T'Y <br /> LL �ENVIRONMENTAI HEALTH DEPARTMENTy <br /> 00 last Main Street,Stockton,CA 95202-3029 <br /> �{ Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwsjgov.arg/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility blame: _ - <br /> 1 11 W 1 `F C l j%6, Page_�of ! <br /> Facility Address: city:, Inspectio Date: <br /> ?/ Iva - z 3 0 <br /> FA#: -PR#: �U � Program l;,kpj:,-A <br /> © <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of.petroleum z 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#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 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 /> 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: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product-Type: <br /> Total Capacity: gallons ' <br /> Install Date: <br /> (per 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 Protl duct 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 /> E (per tank or cumulative for containers by product type) Install Date: <br /> 73 Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> f <br /> t <br /> EHD Inspector: Reviewed Date: Entered Date;, <br /> By Initial: (� �.p� By-Initial: (�L <br /> EHD 28-01 <br /> 01116!08 <br />