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} SAN JOAQUIN COUNTY' t r .( ;NVIRONMENTAL HEALTH DEPARTMENT /! / rr r� 0 East Main Street, Stockton,CA 95202-3029 V Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY:FORM Facility Name: Page of r Facility Address: city: lnspeetiop Date: FA#: PR#: Program Element: � b'3 F3 Tank/Contain&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) ❑ Containers2821 r ( ) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) 1 Product Type: 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 450 gallons) 2 Product Type: 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 450 gallons) 3 Product Type:a' Total Capacity: gallons (per tank or cumulative for containers by product type) Install'Date:r I ❑ Tank(2820) 11 Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 ' 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) i : 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install,'Date: Total Capacity this Page: ro -6 gallons Total Capacity for Site: gallons Comments: d ;S Ne?` . Iv1�. T t 3�a iI✓� irfl /Ia,,.S ;. ry cr 7##e,9Ly "a EHD Inspector: Reviewed Date: Entered Date: By Initial: „� -t�� By Initial: EHD 28-01 I 01/16/08