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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> _Mfoo <br /> East Main Street,Stockton,CA 95202-302 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web r www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: /�, Page of <br /> hCity:. C�� InsP <br /> ec <br /> s. <br /> Facility Addres <br /> �z A/ 'J4// LCo sr <br /> FA#: /� 1 C PR#: Program Ele <br /> [ <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 e. <br /> El Tank (2820) 1� Containers (2821) #of Containers: TA#: <br /> (>250 gallons) ,(>55 gallons and<250 gallons) <br /> 1 Product Type: - <br /> Total Capacity: _, ! �, __gallons <br /> (per tank or cumulative fo product type) Install Date: <br /> ❑ Tank (2820) Gil6ntainers (2821) #of Containers: TAM <br /> i' (>250 gallons) (>55 gallons and X250 gallons) 7 <br /> 2 Product Type: CJ/ <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) 4 retainers (2821) #of Containers: TA#: <br /> (>250 gallons) _(?55 gallons and a250 gallons) <br /> 3 �. ,Product Type: <br /> Total Capacity` .S � gallons Install Date: <br /> (per tank or cumula..., y product type) <br /> ❑ Tank(2820) Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: ii, •� gallons Install Date: <br /> + (per tank or cumulative for containers by product type) <br /> EI/Tank (2820) LJ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and a250.gallons) -1 --r <br /> 5 Product Type: <br /> Total Capacity: r� 2-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 2 ','1 If gallons Total Capacity for Site: gallons <br /> Comments: <br /> r <br /> i <br /> EHD Inspector: Reviewed Date: Entered Date <br /> By Initial: q '�'� By Initial: <br /> ] <br /> EHD 28-01 <br /> 01/16/08 <br />