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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTNIEN' <br /> 600 East Main Street,Stockton,CA 95202-3029' <br /> Telephoner(209)468-3420 Fur:(209)468-3433 Web:www.sjgov.org/chd <br /> ABOVEGROUND PETROLEUM'STORAGE PROGRAM SURVEY FORM <br /> Facility Name:o <br /> �rloq Z,ifAIA2 l 6;06� D Page f _ _of <br /> Facility Address: : City: Inspectio to <br /> & /OF <br /> FA#: PR#: Program Element. <br /> 7 :V <br /> R Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum Z 1320gallons in tanks and containers over 55 gallons. <br /> Com tete one box for each tank or each cumulative container product type., <br /> ank (2820) ❑ Containers (2821) #of Containers: T.A4 <br /> (>250 gallons) (>55 gallons and<250 gallons), <br /> 1 Product Type: ,. <br /> Total Capacity: ,5_0 0 gallons Install Date:,(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 /> 2 Product Type: . <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (282 1)rt . #of Containers: TA#: <br /> (>250 gallons) (>55,gallons and<250 gallons) i <br /> 3 7 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 /> El <br /> ate:❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons), (>55 gallons and<250 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: ganonsl gallonsTotal Capacity'for Site: gallons <br /> Comments: <br /> 2-o 11P 94 <br /> EHD Inspector: Reviewed Date: Entered Date <br /> "By Initial: dr.1-5.04 By Initial: <br /> EHD 2801 <br /> 01/16/08, <br />