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SAN JOAQUIN COUNTY,; <br /> UENV MONMENTAL HEALTH DEPARTMENT <br /> 4- Z� <br /> 600 East Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:wwwsjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: [* Page Of / <br /> Ami, 71-4 <br /> Facility Ad rens: City: Inspection Dat <br /> O D 4F oB <br /> PR#: <br /> FA#: <br /> Program Element: <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 /> Cam lete one box for each tank or each cumulative container product type. <br /> Tank(2820) ElContainers"(2821) "#of Containers:' TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: Ilk O {�n 2J <br /> Total Capacity: j gallons Install Date: <br /> (per tank or cumulative for containers byproduct type) <br /> ❑ Tank(2820) EO Containers (2821) #of Containers' � TA#: . <br /> (>250 gallons) (>55-gallons and<250 gallons) <br /> 2" Product Type: A <br /> Total Capacity: 1 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) " ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> El Tank(2820) ❑ Containers (2821) #of Containers: TA#: <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 (282 1)" #of 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: [/. 7 gallons <br /> Comments: <br /> 3"2.d <br /> EHD Inspector: Reviewed Date: Entered Dat : / <br /> IV2 By Initial- (Jt,�� By Initial: <br /> 1/J <br /> EHD'28-01 V <br /> � 0111610$ <br />