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SAN JOAQUIN COUNTY <br /> OVIRONMENTAL HEALTH DEPART <br /> 600 East Main Street, Stockton,CA 952029 <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 /> /^�N f ��/iO1�'7_ -72? Cy Page Z o <br /> Facility Address: City: Inspection Date: <br /> lD <br /> FA#: PR#: Program lement: <br /> Al <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >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) #of Containers: TA#: D5 )(p$QG] <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: v <br /> Total Capacity: /G 0 D gallons loccol m )-6( A <br /> (pr tank or cumulative for containers by product type) Install Date: <br /> 197erTank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: /d G D gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Tank (2820) ❑ Containers (2821) #of Containers: _ TA#: SSI la`gI l <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3Product Type: ,. <br /> Total Capacity: .S4 4 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: T�A#: 0� <br /> (>250 gallons) (>55 gallons and<250 gallons) � "-X- -� <br /> ) <br /> 4 Product Type: /� <br /> Total Capacity: // d 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 /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 2- gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered ate: <br /> By Initial: By Initial: <br /> EHD 28-01 !/ U <br /> 01/16/08 <br />