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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �1400 East Main Street,Stockton,CA 95202-302%r- Telephone:(209)468-3420-Fax:(209)468-3433 Web:www.sjgov.org/ehd. T ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEYFORM Facility Name: Page of Facility Address: e)rd7 City: Inspection Date: Program Element: FA#: PR#: Tank/Container Information g" Complete for all sites with cumulative aboveground storage of petroleum 2.1320 gallons iii 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) �L Q lProduct Type: Total Capacity: .7 S gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of,Containers: TA#: w (>250 gallons) (>55 gallons and<50 gallons) 2 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) 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 ype:. _Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: Ss' gallons Comments: EHD Inspector: Reviewed Date:.Initial: Date: By Initial: wO By Initial: O B EHD 28-01 01/16/08