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SAN JOAQUIN COUNTY "NV1RONMENTAL HEALTH DEPARTMENT o00 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: �/ U/'n 1 T A t1G )C/A -- Page�—of�— Facility Address: City: Inspection Date: l 9 ro/ N' G th W N FA#: PR# Program Element: /0 �l Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ank(2820) ❑ Containers (2821) #of Containers: TA#: t9 (>250 gallons) (>55 gallons and<250 gallons) c 1 Product Type: �a�� Total Capacity: gallons (per 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: ,S p D 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: gallons Total Capacity for Site: �Q�"p gallons Comments: ,Z p r d EHD Inspector: Reviewed Date: Entered Date: CBy Initial: �,�_a By Initial: a �/ EHD 28-01 01/16/08