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SAN JOAQUIN COUNTY <br /> *NVIRONMENTAL HEALTH DEPARTMENT <br /> 600 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 /> Page Z of >/ <br /> Facility Address: City: Inspectio ate <br /> 3 <br /> FA#: PR#: Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Ile Complete one box for each tank or each cumulative container product <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: 7p <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 1 Product Type: <br /> Total Capacity: 106 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 19 <br /> ❑ Tank(2820) Ca�ontainers (2821) #of Containers: TA#: j9 5 /!e/4 7 <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 2 Product Type: yze/ <br /> Total Capacity: / ZD gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ElTank(2820) R/ <br /> Containers (2821) #of Containers: _TA#: 6 <br /> (>250 gallons) (>55 gallons and<250 gallons) / <br /> 3 Product Type: (Til~i0/L2671 <br /> Total Capacity: 9 Z—U gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank(2820) ETIcontainers (2821) #of Containers: TAM O / <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> 4 Product Type: Gv.QI -,f5Aft/T/ <br /> Total Capacity: .�O 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: q o gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />