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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN- j00 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: ,�/ /� //'/ c,- Page_--;, - of Facility Address: / ,j City: Inspect io D e: z l d� FA#: PR#: Program Element: 4057/&/,e Zr!2 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Com to one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (282 1) #of Containers: Z— TA#: 5-170 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 0� Total Capacity: /t!�) gallons (per tank or cumulative for containers by product type) Install Date: ll-Tank (2820) ❑ Containers (2821) #of Containers: TA#: / yfl � (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 7' Total Capacity: fp 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) 3 Product Type: Total Capacity: 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) 4 Product Type: Total Capacity: 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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: O gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered / �n Date: By Initial: By Initial: EHD 28-01 01/16/08