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SAN JOAQUIN COUNTY _ •NVIRONMENTAL HEALTH DEPARTMENT v.4 "960 East Main Street,Stockton,CA 95202-3029 Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY JFORM ) Facility Name: Page / Of / Facility Address: �� /�City: Ins ectio Date- // S-'7J / C' J G //�� [ FA#: PR#: Program Element: 70� 2B L14 0 Tank/Container Information Compl to 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) ❑ Containers (2821) #of Containers: l TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 / / �� 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<50 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ 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: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers typ by product e) Total Capacity this Page: V v gallons Total Capacity for Site: gallons Comments: tHD Inspector: / Reviewed tate: ,/ En[eredal Dale: B By Initial: l�•a�-0'1 Y Initi EHD 28-01 01/16/08