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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN_ 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 of Facility Address: City: Inspet,D%j*, FA#: 000 �S� PR#: /� Program El t. S � 2 svv(( Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers er 55 gallons. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: / 000 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank 2820 al ontainers 2821 / ( ) ( ) #of Containers: T #: 0,611e Tg� (>250 gallons) (>55 gallons and<250 gallons) �. 2 Product Type: Total Capacity: / 'Z !J gallons 000 (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) l,(containers (2821) #of Cont ' ers: Z TA#: 445 � (>250 gallons) (>55 gallons and<250 gallons) 3 Produ ype: p Total Capacity: O� gallons (per tank or cumulative for containers by product type) Inst I Date: ❑ Tank(2820) Ea ontainers (2821) #of Containers: TA#: d, I!e7 q_3 (>250 gallons) (>55 gallons and<250 gallons) ' 4 Product Type: � � Total Capacity: -s gallon (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers 821) #of Containers: TA#: (>250 gallons) (>55 gallons and< 0 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers product type) Install Date: Total Capacity this Page: .�� gallons FTotal Capacity for Site: / , gallons Comments: ZVL EHD ector: Reviewed Date: Entered Date: r3 r By Initial: �`B By InitO D22d 8-01 01/16/08