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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <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 7—of <br />Qd <br />Facility Address: City: <br />Inspecti Dat . <br />D � . lam. i•1l.) 1 <br />,j(�� <br />FA #: <br />PR #: <br />Program EI menta <br />�D <br />3-- <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 />Rl"Tank (2820) ❑ Containers (2821) #of Containers: TA#: Oq <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) / � <br />Product Type:--i�----1-- � , ✓ <br />t <br />Total Capacity: d V ti gallonsInstall Cr <br /> <br />(per tank or cumulative for containers by product type) <br />_ <br />� Tank (2820) ❑ Containers (2821) #of Containers: TA#: 061 l �� <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: <br />,��% gallons mt,f-' eA: ,4 tlxy4n" I <br /> <br /> tank or cumulative for containers by product type) <br />Tank(2820) El Containers (2821) #of Cont <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: 1✓/ I n(ja 6V (,�x$rttnu <br />Tot <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />