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SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMEi 00 R r 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: v1� Page of Facility Address: City: Inspection Date: r r l FA#: PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Co Wlete one.box for each tank or each cumulative container product type. ❑ Tank(2820) Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 0/ Total Capacity: f,g' gallons (per tank or cumulative for containers by product type) Install Date: 11 Tank(2820) C9'Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 � Product Type: Total Capacity: _gallons Install Date: (per tank or cumulative for conte—. by product type) 20 ❑ Containers (2821) #of Containers: TA#: (>250 gallons) 3 Total Capacity: Z O gallons /3 (per tank or cumulative for containers by product type) '7 3 Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons tions and<250 gallons) 4 duct T e: �jl/A�'T� O L Total Capacity: O� gallons S� �/ (per tank or cumy*ve for containers by product type) Install Date: �Sq ❑ Tank(2820) Containers (2821) #of Containers: �^ #: � (� (>250 gallons) (>55 gallons and<250 gallons) A 5 Product Type: Total Capacity: / / d gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: 2 ri EHD Inspector: Reviewed Date: Entered Da[ By Initial: By Initial: Rol 4 n EHD 28-01 !� 01/l6/08