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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT y ASO 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 FORM Facility Name: Page of Facility Address: City:� . Inspection C IVZ at I ? , D FA#: PR#: Program ent: OsoW*7 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 ank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: LL Dy gallons (per took or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) Product Type: Total Capacity: 3 er ogallons Mall Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: _ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAO: (>250 gallons) (>55 gallons and<250 gallons) 4 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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 40 gallons Total Capacity for Site: 2670 gallons Comments: 1 3 24 �/off EHD Inspector: Reviewed Date: Entered Date: C/ By Initial: �(�l-v� Ry Initial: EHD 2"1 01/16/08