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SAN JOAQUIN COUNTY - #NVIRONMENTAL HEALTH DEPARTMEN' -. 00 East Main Street, Stockton,CA 95202-302 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: Cit Inspect' n Da FA#: PR#: Program Ele enh' � Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons'in tanks and containers over 55 gallons. Com to one box for each tank or each cumulative container roduct type. ❑ Tank (2820). Containers (2821) #ofContainers: TA#. ' (>250 gallons) (>55 gallons and 450 gallons) 1 Product Type: 1414 S 7dF di Total Capacity: / gallons (per tank or umulative for containers by product type) - r, Install Date... xlp� ank(2820) ❑ Containers (2821) *of Containers: ,,,TA#: (>250 gallons) (>55 gallons and X250 gallons) 2 Product Type: Total Capacity: - Z2. gallons k (per tank or cumulative for containers by product type) Install Date: , ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and a250 gallons) 3- Product Type: . Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) El Containers (2821) . #of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 4 .Product Type: Total Capacity: gallons (per tank or cumulative for containers byproduct type)- Install Date- ❑ Tank(2820): ❑ Containers (2821) #of Containers: TA#:- (>250 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: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: EnteredDate: I .By Initial: ? ,�,1.04 By Initial: l� 5 EHD 28-01 01/16/08