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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEI <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 /> Page ` of <br /> R <br /> Facility <br /> �Address: � 0 / City: Inspection Date- <br /> // • r f/ r 0 " <br /> FA#: PR#: Program Element: <br /> fA0000 -- 9 I PfiGSi6jl !�- 283 / <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 /> UJ"/Tank (2820) ❑ Containers (2821) #of Containers: TA#: dIfl z1ZZ� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: �/Y <br /> � -S <br /> Total Capacity: do gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> C'Tank (2820) ❑ Containers (2821) #of Containers: TA#: ,Q 6-1/11(](Q $ <br /> (>250 gallons) (>55 gallons and<250 gallons) /- <br /> 2 Product Type: <br /> Total Capacity: ,S'o d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [Tank (2820) ❑ Containers (2821) #of Containers: TA#: A 5/LeQ GP ! <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: S�I0 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: 500 gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: \ Reviewed D e: Entered Date: / <br /> By Initial: By Initial: 0 0 <br /> EHD 28-01 <br /> 01/16/08 <br />