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F SAN JOAQUIN COUNTY kr t PENVIRONMENTAL HEALTH DEPARTMENT "140900 East'Main Str6et,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: 1 - -- , Page of Facility Address: City: 'J Inspectio Date A v I V 7 fy, H FA#: PR#: Program e t Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container producttype. Tank(2820) ❑ Containers (2821) .#ofContainers: + TAM (>250 gallons) (>55 gallons and<250 gallons) 1 .3 Product Type:- Total Capacity: 22. D 0 gallons (per tank or cumulative for containers by product type) Install Dater ❑ Tank(2820) ❑ Containers (2821) :#of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: i ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) t 3 Product Type: Total Capacity: gallons 1 (per tank or cumulative for containers by product type) Install Date' ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and 450 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date' e ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: j gallons Total Capacity for Site: d gallons i Continents: I i ti ' EHD Inspector: --T—Reviewed Reviewed Entered Date: --�'� � �`,� S, By Initial: By Initial: EHD 28-01 01/16/08 i