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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN i 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 Facility Ad ess: Inspection Date: 161 D 4 P1CG l o FA#: PR#: a/,' $S' Program Element: 00032 L 7 -Fr 2? 3 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. ❑ Tank (2820) X Containers (2821) #of Containers: TA#: &M&12 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: G*�1,t,(.i& d; 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:�� s) 2 Product Type: �IC� Total Capacity: app _ s Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) XContainers (2821) #of Containers TA#: 6,6-j 4,06--;,) (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: 0i Total Capacity: 7i gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: 1 TA#: l,Sl 4ef,�3 4 (>250 gallons) (>55 gallons and<250 gallons) Type:Product T e: DI � Total Capacity: 9 0 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: L7 2 gallons Comments: EHD Ins n- Reviewed Date: Entered Date: By Initial: By Initial: EHD 28-01 01/16/08