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SAN JOAQUIN COUNTY _ <br /> —'NVIRONMENTAL HEALTH DEPARTMEN' <br /> o00 East Main Street, Stockton,CA 95202-302-,, <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 /> L lWo <br /> S ! Page / of <br /> Facility Address: City: Inspectio Date: <br /> ' /, <br /> FA#: V tR#: Program Element: <br /> Qao � �33 S( 1" 2 � 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 ontainer product type. <br /> Tank (2820) ontainers (2821) # f Cotai l' ".=F )`2'710A'7 <br /> (>250 gallons) r5ons d«SO galla s) �"'�2 uct:'Type: <br /> Total Capacity: ' b`aHotysI sfa-A Bate: <br /> (per tank or cumulative,jpr.�entalnVH y product type) S <br /> Tank(2820) ❑ Container 821) of_CAtainers: <br /> (>250 gallons) (>55 gallons and S0'ga�3u,Is) '- .+ <br /> Total Capacity: 0 ..gel s <br /> (per tank or cumul y product type) InstvUl Date: <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: ] o 'FD tL b (/ <br /> Total Capacity: D d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) ❑ Colntain s '2 821) #of ntainel TAr#: <br /> (>250 gallons) (>55 galons and 50 ga s� , <br /> 4 P u ..T,YPer-..�,xf1�-�' <br /> Total Capacity: 0Instaall Date: <br /> all�lgls 2 `` <br /> (�tank or cumulative for o„op 3jA—br 5fdd�uc`t type) l <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: J gallons I Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Dat <br /> 1 By Initial: V�r� -)te l%-Ot By Initial: �[ <br /> EHD 28-01 <br /> 01/16/08 <br />