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SAN JOAQUIN COUNTY &ENVIRONMENTAL HEALTH DEPARTMENT 00 East Main Street,Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page_�of Facility Address: City: Inspee'on te- �oe6 LIAO >- e FA#: PR#: / / �� Program Element: I S- zX3 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 type. El"Tank(2820) ❑ Containers (2821) #of Containers: TA#: 1 (>250 gallons) (>55 gallons and<250 gallons) Product Type: Total Capacity: '2-® '0 m gallons (per tank or cumulative for coE ' ers by product type) Install Date: / El Tank(2820) ntainers (2821) #of Containers: / TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 01 L Total Capacity: Z �� gallons Install Date: er tank or cumulative for containers by product type) ❑ Tank(2820) fr Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: &Y-22Ro4 Total Capacity: Z�(] gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) N3 Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type:1V14 57-11::: C7'-' Total Capacity: 2- 4-0 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 Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: -2-7 Z 0 gallons I Total Capacity for Site: Z 'J Z gallons Comments: EHD Inspector: Reviewed Date: Entered Date: s By Initial: .N.psd By Initial: EHD 28-01 0l/16/08