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SAN JOAQUIN COUNTY ' <br /> i -NVfRONMENTAL HEALTH DEPARTMEN- <br /> 600 East Main Street, Stockton,CA.95202-302Y- <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 /> Page 2. of <br /> Facility Address: City: Inspect' ri D te: <br /> FA#: PR#: ram ement:Pro El <br /> ��-- 2 <br /> Tank/Container Information <br /> Complete for all sites with cumulative abovegroun&storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumnultitive container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: 6>,,0T <br /> �S <br /> (>250 gallons) (>55 gallons and 450gallons) <br /> 1 Product Type: i2 rim T —. <br /> Total Capacity: 013 b gallons <br /> (per tank or cumulative for containers by product type) Install Date: 2 a <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: h_j <br /> (>250 gallons) (>55 gallons and 4"50 gallons) <br /> 2 Product Type:" i e 5e�'L, *I-L erg, 6el <br /> Total Capacity: 13 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 /> (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 /> 4 Product Type <br /> Total Capacity: gallon_ s Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) ❑ Containers (282 1) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and 450 gallons) <br /> 5 Product Type:.. <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: 5 gallons Total Capacity for Site: Ol, j t3_.- gallons <br /> Comments: <br /> EHD spector: ReviewedDate /If �� Entered Date: <br /> =ByJnitial:— IfJ�e) ylnitiai: -- . <br /> _ EHD 28-01 <br /> 01/16/08 <br />