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SAN JOAQUIN COUNTY "ENVIRONMENTAL HEALTH DEPARTMEN v "u o00 East Main Street,Stockton,CA 95202-34...)—, •-y:,•r Telephone:(209)468-3420 Fax:(209)468-3433 Weh:wrvw.sjgov.org/ehd n F ABOVEGROUND PETROLEUM STORAGE"PROGRAM SURVEY FORM,; Facility Name: Page of Facility Address: City- In"" 'on Aate: c CAA s�� 6 FA#: Progra Elem t: oq Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum"21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank cumu er roduct e. (2820) ❑ Containers(2821) .#ofContainers:` TA#: ( 50 gallons) (>55 gallons and<Z50 gallons) 1 Product Type:'. To Capacity: �D 0 gallons �' (per cumulative for containers by product type) Install Date: IP/Tank(2820) ❑ Containers (282 1) #of Containers: TAM D51 l�n,� (>250 gallons) (>55 gallons and Q.50 gallons) t - 2 Product.Type: . / C-- Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: .. ❑ Tank 2820 Containers 2821 ( ) ( ) ' #of Containers: TAM . (>250 gallons) (>55 gallons and Q50 gallons) 3 t r Product Type: Total Capacity: gallons (per tank or cumulative for contains by product type) Install Date; ❑ Tank(2820) ❑ Containers (2821) "#of Containers:' TA#: (>250 gallons) (>55 gallons and QSO gallons) " 4 Product Type: " Total Capacity: . gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) il#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: Q gallonsTotal Capacity for Site: gallons Comments: Nig �Wiy �Al EHD Inspector: Reviewed t Entered Date: ' C' By initial: , By Initial: t EHD 28-01 01/16/08