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SAN JOAQUIN COUNTY - `�/ ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton,CA 95202-3024 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: O U Page_L of Facility Address: City: Inspection te: z4` / R /4t- �sr_ Low/ i 2 FA#: PR#: Program Element: 32- R I �'±F,2,�'2 40 -7--A7�2 Tank/Container 2- Tank/Container Information Comple 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 protfuct type. Ef Tank(2820) ❑ Containers (2821) #of Containers: TSA#: (>250 gallons) (>55 gallons and<250 gallons) IF 1 Product Type: fi/ 9.0 O I Total Capacity: O 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) Z 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) 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 (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) P55 gallons and<250 gallons) - — 5 Product Type: Total Capacity. gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 3O 8 gallons Total Capacity for Site: 3 00 gallons Comments: 1 3 2-4 d�' EHD inspector. Rmevied t�� B Initial: Date�.5'� ByInitial: tIDate: lD EHD 28-01 01/16/08