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SAN JOAQUIN COUNTY 'NVIRONMENTAL HEALTH DEPARTMENT ) (ft960 East Main Street,Stockton,CA 95202-3029"'; Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM FacilityName: Page of AT r r a . a v T �2 t�w� City: inspecti72. ate: Facility Address: s ' f �y O 7� { D 3 0 d L� L I L Program EI en FA#: PR#: / ,949 Tank/Container Information omplete for all sites with cumulative aboveground storage of petroleum 2t1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product e. Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 2 5-0 gallons Install Date: (per tank or cumulative for containers byproduct type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons. Install"Date: . ' (per tank or cumulative for containers by product type) - c- ❑ Tank(2820) ❑ Containers (2821) " #of Containers: TA#: ! (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons. Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) { t ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>2 0 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity,this Page: �S�d gallons Total Capacity for Site: J gallons Comments: r U 01 J j EHD Inspector: Reviewed Date: Entered " Date: By Initial:" +� �`p- By Initial: �B EHD 2MI t 01/16/08