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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: page Z-- of Facility Address: City: Inspection Date: FA#: PR#: Program Element: q03 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Co tete one box for each tank or each cumulative container product ❑ Tank (2820) Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) Product Type: �<J?A ,v x L V/ 0Total Capacity: / 2,0 gallons (per tank or cumulative fm containers by product type) Install Date: ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) � Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: _ Total Capacity: gallons (per tank m cumulative fm 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 Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers(2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tack or cumulative for containers by product type) Total Capacity this Page: gallons 7 otal Capacity for Site: gallons Comments: EHD Inspector Reviewed Date: Entered bate: By tnitial: By Initial: EHD2Ml 01/16x/08