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SAN JOAQUIN COUNTY N <br /> ` ENVIRONMENTAL HEALTH DEPART10,%�,� <br /> 600 East Main Street,Stockton,CA 95202- 629 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name:je z " <br /> / <br /> Facility Address: IPage of_j <br /> City: nspectio Datc: <br /> / <br /> � <br /> 6 <br /> FA#: - PR#: Program Elemen <br /> C)00 SS d" 7S2, <br /> 7 `7.8C) <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 (282 1) #of Containers:. / TA#: <br /> (>250 gallons) (>55 gallons and X250 gallons) ' <br /> 1 Product Type: <br /> Total Capacity: ,�—d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank 2820 EkC'6ntainers. 2821 <br /> ( ) { } #of Containers: � TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 2 Product Type: Ki La G/ <br /> Total Capacity: gallons " <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank 2820) EVCbffiainers {2821 #of Containers: v <br /> TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: /ly gallons <br /> (per tank or cumulative for containers by product type) Install Date- <br /> Tank <br /> ate:Tank(2820) El Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type:. ©1 ,-�, a� <br /> Total Capacity: ��1-'a� 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<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for coAtainem by product type) Install Date: _ <br /> Total Capacity this Page: Q gallons Total Capacity for Site: ��U gallons' <br /> Comments: <br /> .� 5`2,0, _ ,�GGo <br /> l <br /> EHD Inspector: t Reviewed Date:" Entered Date: <br /> By Initial: By Initial: f7 <br /> EHD 2"1 <br /> 01/16/08 <br />