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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEI` <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 Of j- <br /> D 1900 <br /> Facility Address: City: Inspectippn Datt: <br /> 7 SI f <br /> b o p M it G A � 01 <br /> FA#: PR#: Program Ele ent: <br /> GOO 9/03 S/,f' �g <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2:1320 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#: <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: `I <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 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 /> 3 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 /> ❑ 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: gallons Total Capacity for Site: gallons <br /> Comments: <br /> o ` <br /> zjj <br /> ® )-co o s 44D"5,57 <br /> IC C <br /> EHD Inspector: Reviewed l Date: Entered Date: <br /> By Initial: �� 7'\�' By Initial: l —5LL <br /> EHD 28-01 <br /> 01/16/08 <br />