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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN- o00 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: 0 Page 'z -of 1' I Facility Address: City: Inspection D te: Vii. FA #: PR #:Program Element: D5��e�� 12FS3 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 1 Product Type: 3 ! Total Capacity: gallons Install Date: � (P-pnk or cumulative for containers by product type) Tank (2820)" ❑ Contain s (2821) #of Containers: TA#:% 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: D1 15 S /.F l✓ Total Capacity: gallons Install Date: �- (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: %J l G S's(� Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ,--� I ank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) Product Type: Csc,_ � Total Capacity: gallons (per tank or cumulative for c ntainers 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 Install Date: - (per tank or cumulative for containers by product type) Total Capacity this Page: gallonsl Total Capacity for Site: 7 C1 ? gallons Comments: '-2-t i EHD Inspector: Reviewed Date: By Initial: �� ` . i I ; ) 1 Entered Dat . By Initial: EHD 28-01 01/16/08 1Iu