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SAN JOAQUIN COUNTY �, ENVIRONMENTAL HEALTH DEPARTME?, f 7 ?J o O 6 �I 600 East Main Street,Stockton,CA 95202-3024 / Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name:_ A Page of�- - . dY Facility Addresr. nspec Ibn to �? o FA#: PR#: Program Element: o5a$a g Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product Tank(2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) I Product Type: Total Capacity: /U UO gallons (per tank or cumulative fm containers by product type) Install Date: _ ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative fm 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(282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: 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) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: / CADM lie 1320 rr� LC.or�� EHD Inspector. Reviewed Date: / Entered Date: By Initial: By Initial: 5 a0P( EHD 28-01 01/16/08