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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME�h4 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: f� /� r�. �,/ pj � 1 R_o L��i / �D Page of Facility Address: City: InspectloDate: f 5 �.s'x� VE 1 � r3 0'f FA#: PR#: I Program Etce Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1320 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: TA#: i (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 0X I.2g 164/ , D/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) E:I ontainers (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: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and X250 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#: 0250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 1 ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) $ 'Product Type: Total Capacity: gallons (per tans or cumulative for confiners by product type) Install Date: Total Capacity this Page: gallons 'Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: 'r By Initial: �p•1�•p� By Initial: O �� EHD 28-01 0 t/16/08