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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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:-' `J U Page of Facility Address: 1" City: Ci Inspection DAte FA #: PR #: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. l Tank (2820) ❑ Contaiiners (282 1) #of Containers: TA#: 1 Total Capacity:1#146 l gallons Product Type: 510 (per tank or cumulative for containers by product type) Install Date: r� Tank (2820) ❑ Containers (2821) #of Containers: TA#: Product Type: 5l�b Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: EA Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: -too gallons Product Type: to '-�d (per tank or cumulative Tor containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4Total Capacity:gallons Product Type: $6 -Otb 61 (per tank or cumulative for containers by product type) Install Date: 5b Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 nProduct Type: 141 Total Capacity: (i^yo gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 10 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08