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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEI 600 East Main Street, Stockton, CA 95202-3027 Telephone. (209) 468-3420 Fax. (209) 468-3433 Weh: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Cbhr � Page of _ Facility Address: City: Inspectio Date: FA #: PR #: Pro m ent: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. l -Tank (2820) ❑ Containers (2821) #of Containers: TA#: l�5 (>250 gallons) (>55 gallons and <250 gallons) 1 Product Type: �J Total Capacity: b 8 gallons .10 ( er tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: l! 1L7 (>250 gallons) (>55 ayons and <250 gallons) �- 2 CIL 1 SgC/' L Product Type:. Total Capa allons Install Date: (per tank or cumulative for containers by product type) ank (2820) Containers (2821) #of Containers: TA#: (>250 gallons) (> 5 jgallons and <250 gallons) r 3 Product Type. Total Capacity: _ ga ll Date: ��' u 0 (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page:. gallons Total Capacity for Site: gallons Commen EHD Inspector: Reviewed Date: Entered ' / n Date b -O �� By Initial: 1 By Initial: //�✓.'(/ I /r 1 f EHD 28-01 IC X , I /' 01/16/08 ""