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�.� SAN JOAQUIN COUNTY <br /> NViRONMENTAL HEALTH DEPARTMENT y <br /> 0 East Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY,FORM <br /> Facility Name: ) Page Of <br /> Facility Address: ` City: Iny�l <br /> Date: <br /> 2 R 0 r-%�/� S 1-.r A/r J ./ <br /> #: 1 <br /> PR#: Program.Element: <br /> FA <br /> Tank/Container Inforination <br /> i Complete for all sites with cumulative aboveground storage of petroleum ?1320 gallons in tanks and containers over 55 gallons. <br /> a Com Tete 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: � l/ <br /> Total Capacity: gallons 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 /> 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 X250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by producttype) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 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 /> 1 Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> t. <br /> Total Capacity this Page: gallons Total Capacity for Site: ��� gallons <br /> Comments: <br /> EHD Inspector: ✓ Reviewed Date: Entered Date: <br /> By Initial: Pt�kq"Oft By Initial: ee <br /> ((� <br /> EHD 28-01 <br /> 01/16/08 <br />