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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.Sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: U Page f OF Facility Address: City: Inspectio Dam FA#: �� Is V PR#: _ Program Eleme t: �3 a Tank/Container Information CompI a for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks`and containers*". Complete one box for each tank or each cumulative container product tyEe. Tank.(-2820) ❑ Containers (2821) #of Containers: TA#: 1 c9g Product Type; Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: WTank (2820) ❑ Containers (2821) #of Containers; TAM 2, Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ` L)i Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type. (per tank or cumulative for containers by product type) install Date: ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Data: I ' I ❑ Tank (2820) El Containers- (2821) #of Containers: TAM i 5 Total Capacity: Product Type: p Y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Totai Capacity for Site: gallons Comments: IZ 11 „I�a -z© I. i 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 ot petroleum. O "Container means a storage device designed to be moved when full. I E91 2108 t OAST SURVEY FORM