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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEP <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> C F C G /j�� �� (J (i/�� /✓ Page J of � <br /> Facility Address: City: Ins tion D te: <br /> 93Y4 E. i!fPR SLa Atf q l9 Ok <br /> FA#: Program Element: <br /> o' ��-� 2 g o-b <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#: <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) ❑ 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 (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 rTotal Capacity for Site: gallons <br /> Comments: <br /> T ,yo CIe fIMP S <br /> &v t <br /> 77(��9T, <br /> ered Date: <br /> EHD Inspector: Reviewed Date: Ent <br /> By Initial: ,n t1 By Initial: /A� <br /> EHD 28-01 1/ <br /> 01/16/08 <br />