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a y SAN JOAQUi N COUN' <br /> W 'ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 East Main Street,Stockton,CA 95202-301+t+ - <br /> Telephone.-(209):468-3420 Fax:(209)468-3433"We&.www.sjgov.org/ehd " <br /> ABOVEGROUMD PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility ame: <br /> Page of <br /> i Facility Address: k City: Ins�/75 <br /> ' <br /> Tj°1 •PPR#: Program Elment: <br /> f nor gam " <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 <br /> ( ) ( ) #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 nta ers y product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: , TA#: <br /> (>250 gallons) (>55 gallons and X250 gallons) <br /> 2 - _ . Product Type: 4_ " <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date- <br /> f ❑ Tank 2820 ❑ Containers 2821 <br /> Tank(2820 ( ) #of Containers: TA#: <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: 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 /> S Productfiype:" <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: .S` gallons <br /> Comments: <br /> l� zo rows <br /> EHD Inspector: Reviewed Date: Entered Date"_ <br /> By Initial: (11_ -� By Initial_ [C1r <br /> l <br /> EHD 28-01 <br /> 0l/16/08 <br />