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SAN JOAQUIN COUNTY <br /> t :NVIRONMENTAL HEALTH DEPARTMENT <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 Y✓ C Page of <br /> Facility Address: City: Inspection Date: <br /> FA#: PR#: Program Element: <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: J TA#: 0 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: 0 <br /> Total Capacity: s�� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) Containers (2821) #of Containers: l TA#: 4j <br /> (>250 gallons) (>55 gallons and<250 gallons) ` <br /> 2 Product Type: �}/ �1 a <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date. <br /> ❑ Tank(2820) ftJ Containers (2821) #of Containers: / TA#: l(P Q <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: rs gallons Install Date: <br /> ElB(per tank or cumulative for containers by product type) <br /> Tank (2820) 'Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: 1-S gallons ' <br /> Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: �� �g <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: Z3�-jSl r <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspect 9c�. Reviewed Date: Entered Date: <br /> C_ d <br /> By Initial: By Initial <br /> EHD 28-01 <br /> 01/16/08 <br />