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SAN JOAQUIN COUNTY l "• . ENVIRONMENTAL HEALTH DEPARTMEN' 00 East Main Street, Stockton,CA 95202-302, :. Telephone:(209)468=3420 Fax:(209)468-3433.Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM' Facility Name: ]�� Page of {7 � r 'f City: inspect n Date: Facility Address: _�� N ' (J 2� p� 2 o ' /YI Q . FA#: PR#: Program Element: ._ i Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2!.l 3 20,gallons in tanks and containers over 55 gallons. Com Tete one box for each tank or each cumulative container product type. , 4 ❑ Tank(2820) Containers (2821) #of Containers: . (>250 gallons) (>55 gallons and X250 gallons) , 1 uct Type: Zr7 Total Capacity: a ons \ (per tank or cumula ontainers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: - TAM 4 (>250 gallons) (>55 gallons and<250 gallons)' i 2 Product Type:' 8 Total Capacity: -2- _gallons . 5 (per tank or cumulative for containers by product type) Instal Date: ❑ Tank(2820) -M,6ontainers (282 1) #of Containers:- TAM (>250 gallons) . (>55 gallons and 0250 gallons) 3 Product Type: A/ Total Capacity: 2-0 d - gallons < (per tank or cumulative for containers by product type) Install Date: p - ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons)0 (>55 gallons and<250 gallons) 4 Product Type: .4- Total Capacity: gallons- �, (per tank or cumulative for containers by product type) Install Date: ! ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type:. { Total Capacity: gallons t (per tank or cumulative for containers by product type) Install Date: s Total Capacity this Page: gallons .Total Capacity for Site: gallons } Comments: f - EHD Inspector: ReviewedDate: Entered Date: �7 By Initial:-_� ,� �.yry•Q� By Initial: o`Z7 a EHD 28-01 01/16/08