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t SAN JOAQUIN COUNTY . ,NVIR0NMtNTAL HEALTH DEPARTIvIENTt jA16 W 0 East MainStreet, Stockton,CA 95202-3029 Telephone:(209)468-3420 Falx:(209)468-3433 Web:wwwsjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY.FORM Facility Name: t/�L Page Facility Address:,, City: Inspection Date- Z4,5-6 6 Z r— FA M. PR#: Program Element: B G(J r Tank/Containeir 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. ' 471"Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: S"'rr o 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) 2 Product Type: Total Capacity: gallons Install,Da#e: (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 (282 1) #of Containers: -TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons Installbate: (per tank or cumulative for containers by product type) F ❑ Tank(2820) ❑ Containers (2821) #of Containers: s TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 _ Product Tyke: Total Capacity: gallons (per tank or cumulative for containers by product type) Install bate: Total Capacity this Page: gallons Total Capacity for Site: l9'fl gallons Comments: 3 t� l'.C� o EHD Inspector: Reviewed Date: �7 By Initial: By Initial: EHD 2M I 01/16/08-