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' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ~ <br /> (J600 East Main Street,Stockton;CA 95202 30 <br /> - � <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwsjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE_ PROGRAM SURVEY FORM <br /> F <br /> y Name: Pa e ofty Address: City: Inspection D e: <br /> FA#: PR#: Program Ele ent: <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 /> Com lete 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 450 gallons) � <br /> 1 Product Type: <br /> Total Capacity: 0-e;? —gallons <br /> (per tank or cumulative for containers by product type) Install Date:2`47ank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) D <br /> 2 Product Type: 6 <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 450 gallons) <br /> 3 Product Type: aT0 D� <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank (2820) PI Containers (2821) . #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: 1 f 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 /> (per tank or cumulative for.containers by product type)' Install Date: <br /> r <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> F. <br /> EHD Inspector: / FR ie-ed Date:� ,,// Entered Date:� By Initial: �(� �� �'8t By Initial: !� <br /> EHD 28-01 <br /> 01/16/08 <br />