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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 00 East Main Street,"Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd, .ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / Page-L—of j— Facility Address: J City: Inspectio D e DIL Q� FA#: _ PR#: Program Ele 19 *Z11 19 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320-gallons in tanks and containers over 55 gallons. Copiplete one box for each tank or each cualive containe roduct type. ❑ Tank(2820) Containers (2821) #of Contal ers: 1. #: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 'L.S� gallons (per tank or cumulative for containers by product type) Install Date' i ❑ Tank(2820) ❑ Containers (2821) #of Containers: -_ TA#: (>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) t 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 450 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: r Total Capacity this Page:' gallons Total.Capacity for Site: 1- 36 gallons Comments: �D a�✓ } EHD Inspector: �) Reviewed ( Date: Entered Date: ✓/UIJS By Initial: ,1 J- -�. ), By Initial: Q EHD 28-01' 01/16/08