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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN', 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: cw i SNI �11 Page 2 of Z ( Facility Address: City: Inspection Date: FA 4:4t PR #: Program? Element: I /vV✓I Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_ 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) X Containers (2821) #of Containers: TA#: _ 3 1 (>250 gallons) . (>55 gallons and <250 gallons) Product Type: o�� e{ Total Capacity: 108 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: I TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) ^� Product Type: QI a' Rle r Total Capacity: (f ft gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: I �� gallons Total Capacity for Site: � gallons Comments: EHD Inspector: Reviewed By Initial: D t V Entered Date: By Initial: EHD 28-01 01/16/08