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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '^600 East Main Street, Stockton,CA 95202-302w- Telephone. (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: , Page '7- of Facility Address: City: Inspec�Gon V QOV FA#: PR#: Program Element: Tank/Container Information Complete for all sites with cum lative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Co fete one box for each tank or each cumulative container product type. ❑ Tank(2820) EVContainers (2821) #of Containers: _� TfA#: 6� ; (>250 gallons) (>55 gallons and<250 gallons) �� I Z 1 Product Type: // �� o�� Total Capacity: �0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM (>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<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: 6 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date- Entered Date: By Initial: Wt� S4q,. By Initial EHD 28-01 01/16/08