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• SAN JOAQUIN COUNTY #ENVIRONMENTAL HEALTH DEPARTMEft 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: o vps Page , of—�— Facility Address: City. In[_sp�e�c/tj�on [e: FA#: Q T #• J // '>'P Program Element: S/S ' 3 Tank/Container Information Comple 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 t e. Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 2��.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) 2 Product Type: Total Capacity: gallons (per rank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (282 1) #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: gallons I Total Capacity for Site: gallons Comments: v.Cli Tf�tik yrJ S T,��=�ry c �-io v �� T /c Is C 13 zo �AL�o.�s Q AZ k1-0,116 2-0 3 14 zZD EHD Inspector: Reviewed Entered Date_: By Initial: 67-1_lo By Initial: EHD 2M I Cvt 01/16/08