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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME* 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name; , Page ( of Facili Address: t City: Inspection Da[e: FA#: 13 40 ^ PR#: ProgrW Element. d O 0�1 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. Tank(2820) ❑ Containers (2821) #of Containers: / TA#: MO_ 250 gallons) (>55 gallons and<50 gallons) 1 Product Type: Total Capacity: 600 gallons (per tank or cumulative for containers by product type) Install Date: R Tank (2820) ❑ Containers (2821) ##of Containers: TA#: D Sc?Oc�B I (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Ol Total Capacity: I7i0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<50 gallons) 3 Product Type: Total Capacity: 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) 4 Product Type: Total Capacity: 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 (per tank or emulative for containers by product type) Install Date: Total Capacity this Page: &VOO— gallons Total Capacity for Site: gallons Comments: Y S J ✓ ky1( EHD or. Reviewed Date: d Entered Date -- By Initial: .yob By Initial: EHD2MI �C v 01/16/08