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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: Page of 0 5 �Nr Gi si W VJ C,, G,6Al/, g Facility Address: City: Ins cti ' 7 V�17 FA#: PR#: Program Element: 3 — d5o2S/ 5- Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ;2! gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank(2820) ❑ Containers (2821) #of Containers: J TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 0 / Total Capacity: Z/-0 d gallons (per tank or cumulative for containers by product type) Install Date: ank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative R iltainers by product type) Install Date: nk(2820) ❑ Containers (2821) #of Containers: TA#: T(4> 5101— > 50 gallons) (�55 gallon- d<250 gallons) 3 1� Product Type: Total Capacity: _ gallons (per tank or cumulativL.ror containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: l TA#: ' (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: � Total Capacity: g S gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) $ 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: Entered ate: By Initial: By Initial: EHD 28-01 01/16/08