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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: (Page �lil�t�r o 1 � � DI�.I Z of Z Facility Address: tom✓ �1>� City: �rv:� C�-1 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. C�1 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: C gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) V Containers (2821) #of Containers: ` ` TA#: 2yu��ll Total Capacity: VU gallons Product Type: e o�� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: > Total Capacity: gallons Product Type: -- (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: �j� gallons Total Capacity for Site: n� allons 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