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SAN JOAQUIN COUNTY <br /> 'ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: Page 1 of <br /> Facility A�}dress: ( � n City: Inspection Date: <br /> LOcc( Z$ O%l <br /> FA#: PR#: Program Element: <br /> 369 2S-2 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product <br /> Tank(2820) ❑ Containers (2821) #of Containers: 1 TA#: /9/ /,h 57 <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 1 Product Type: 1, / <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ,E' Tank(2820) ❑ Containers (2821) #of Containers: TA#: i9<<i�u $u S <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 2 Product Type: <br /> Total Capacity: Zoos gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ji�,Tank (2820) ❑ Containers (2821) #of Containers: 4' TAM <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 3 Product Type: Waste c>,I <br /> Total Capacity: L(-So 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 Q50 gallons) <br /> 4 Product Type: <br /> Total Capacity: 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 Q50 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: 7(,� �j'O gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector Rcvicwed I Date: Entered Date: <br /> EHD 28-01 VVV <br /> 01/16/08 <br />