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ENZSAN JOAQUIN COU NVIRONMENTAL HEALTH DERTMEi 0 East Main Street, Stockton,CA 95202-30 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Y Page r of Facility Address: City: Inspection Date: r FA#: PR#: Program Element: !lP '1� o ass D� Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. Com lete one box for each tank or each cumulative container product ❑ Tank(2820) Containers (2821) #of Containers: 7� TA#: Q ,A (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 11-6 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ontainers (2821) #of Containers: v TA#: i9 /Ze 0 (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: (�G Total Capacity: _ /z Z2, gallons (per tank or cumulative forOR/Containers(2821) ontm aers by product type) Install Date: El Tank(2820) OR/Containers(2821) #of Containers: TA#: fiZS/ZCC�;3 (>250 gallons) (>55 gallons and<250 gallons) 3 --r Product Type: 0/ /—, ��iAH//✓ ON�!?�" 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 i7 Product Type: fl4 Total Capacity: S gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2 820) ❑ Containers (282 1) ##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: 3 z> gallons Total Capacity for Site: gallons Comments: 02. EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: 7 �/ EHD 28-01 r 01/16/08