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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-302Y <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: Page Z- of <br /> Facility Address: City: Inspection r�lr/r <br /> FA#: PR#: Program E eme : <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#: a5 1 le �3 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) EZ/Containers (2821) #of Containers: g TAM ©e/(Q ✓3 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: o/ L <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ntainers (2821) #of Containers: TA#: <br /> (>250 gallons) �5V�jgaollons and<250 gallons <br /> 3 3 Product Type: H yb&o L)C� v L <br /> Total Capacity: ga ons <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 /> 4 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 /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Z tZ 'J Z gallons FTotal Capacity for Site: gallons <br /> Comments: <br /> ba <br /> ib <br /> EHD Inspector: Reviewed Date: Entered Date: U <br /> By Initial: By Initial: 5 <br /> EHD 28-01 <br /> 01/16/08 <br />