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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT -6600 East Main Street,Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page Of u Facility Address: city: Inspectian Dater FA#: PR#: Progrem Ele t:� j o(0(0(0 "'95w-C3 Z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product ❑ Tank(2820) P--Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) I Product Type: Total Capacity: 5��' _gallons Install Date: (pea tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons Install Date: (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 Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: I'A#: (>250 gallons) (>55 gallons and<250 gallons) g Product Type: _ Total Capacity: gallons Install Date: (per tank or cumulative for containers by product ) Total Capacity this Page: J gallons Total Capacity for Site: S gallons Comments: EHD Inspector: Reviewed Date: Entered Dat y By Initial: vqf� &I.op-+)'"� By Initial: O B EHD 28-01 01/16/08