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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM _ 600 East Main Street, Stockton,CA 95202- Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r L r O Page_L of Facility Address: Ci Inspect' n D te: FA#: PR#: Program E ment: oo� � �o-� o �aQo� 283 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Ek/Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: PA-Q'6& Total Capacity: ra o b gallons Install Date: (per tank or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: DA.e/1c9 Total Capacity: g O D gallons (per tank or cumulative for containers by product type) Install Date: IR/Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: pa Total Capacity: � 0 0 gallons (per tank or cumulative for containers by product type) Install Date: 11 Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: W2� Total Capacity: S b Q 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 FTotal Capacity for Site: gallons Comments: JAAlk-T E 6141 e T` W rVAO 00 r O,P k1 r EHD Inspector: ! Reviewed (�� Date: / Entered Date: / r By Initial: W m By Initial: d EHD 28-01 11 1 u00 01/16/08