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SAN JOAQUIN COUNTY WIRONMENTAL HEALTH DEPARTMENT 600 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: # Page of . �� r� R> O City: -1 inspectio D e: Facility Address: 3 I a SVr r V/r,�Uf. Iti " aR Program lemen FA#: PR#: Tank/Container Information 'k nd storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete for all sites with cumulative abovegrou Com ete one box for each tank or each cumulative container product type. f ( ) #of Containers: � TA#: ❑ Tank(2820) ontainers 2821 (>250 gallons) (>55 gallons and<250 gallons) 4 1 Product Type: i Total Capacity: f 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) p 2 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) r ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type:' . "Total Capacity: 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) 4 Product Type: } Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank 2820 ❑ Containers 2821 Tank(2820 ( } 4of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 5: Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) In Date: + Total Capacity this Page: ' gallons Total Capacity for Site:' gallons Comments: " r ' 3 EHD Inspector: Reviewed Date: Entered Date: -- By InitiaE: �-�"3-'0 By Initial: � �' p � v3 EHD 28-01 01/16/08