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{°Fs .SAN JOAQUIN COUNTY T.- 1 'RONMENTAL HEALTH DEPARTMENT 0 East Main Street, Stockton,C 1 .A-95202-30fi�' Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd 1 r ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facllity blame: �ArN o C f lf' of r?n SSf7A ' SGG✓Ft+2. sl A rage r' l of� Facility Address: City: [nspectio Date: f 6 3 ,Nns �<wy �, o� FA#: PR#: Program Element: . 2� Ll3 Tank/Container Inforrriation Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. f Complete one box for each tank or each cumulative container product e. Tank (2820) ❑ Containers (2821) #;Of Containers: y TA#: (>250 gallons) (;�55 gallons and Q50 gallons) —�� 1 Product Type:. Total Capacity: gallons. (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #o€Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 -Product Type: . Total Capacity:, gallons (per tank or cumulative for containers byproduct type) Install Date'. ❑ Tank (2820) ❑ Containers (282 1) #af 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) 0 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) I11Stall.Date' ❑ Tank (2820) ❑ Containers (2821) #o€Containers: TAM (>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: gallons Comments: i EHD Inspector: Reviewed Date: Entered Ila Date: . By Initial: - , 0�� By Initial: z Q' t- EHD 28-01 01116/08