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air— SAN JOAQUIN COUNTY INVIRONMENTAL HEALTH DEPARTMENT 66 East Main Street,Stockton,CA 95202-3020^-" Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility N.ye: Page of Facility Address: City: CS ,,T on Date: Inspection FA#: PR#: Progro Element: o ® sas7 a o0 2� Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product ❑ Tank(2820) MContainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: �r�/�?b!L b/Z" Total Capacity: 2-5D gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) UrContainers (282 1) #of Containers: TA#:, 2 (>250 gallons) (>55 gallons and<250 gallons) Product Type: W,4 �G pr / / � C/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: _ ElTank(2820) LY"C��ontainers(2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3Product Type: IJ T,T Total Capacity: S,s gallons (per tank or cumulative for containers by product type) Install Date: _ ❑ Tank(2820) ❑ Containers (282 1) #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 Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: Zj- 70 gallons Total Capacity for Site: , gallons Comments: EHD Inspector: Reviewed Dale:p ;jf Entered Date: By Initial: GtL 0 �� By Initial: � Y EHD 28-01 01/16/08