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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR ?N AV 600 East Main Street, Stockton,CA 952vL-302Y Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: � �� l � � ) tJ�S � � � �� g/ I Pae ,of Facility Address: City: Inspectio Date• FA#: PR#: Progrim Ele ent: 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#: C5,-4& (>250 gallons) (>55 gallons and<250 gallons) 1 �U O � Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: /2 o,(45f14!? (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Vr7 /'q,f Total Capacity: 5 0 4 19 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820 Containers(2$21.), #of Containers: TA#: �, (>250 al (>55 gallons and<250 gallons) 3 Product Type: n�'��i=—� nil Total Capacity: �p--P�--� ��-�gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (282 1) #of Containers: (>250 gallons) (>55 gallons and<250 gallons) n 4 Product Type. nip Total Capacit Z�� 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: +';', gallons Total Capacity for Situ— gallons Comments: EI-IC�Inspector: Reviewed Date: �g Entered Date �1 ' By Initial: `•2°� By Initial: `9 s7 _ G !/ EHD 28-01 01/16/08