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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM URVEY FORM Facility Name: Page of i Facility Address: //^w'/l/.' City: 7_/z- Inspection ate: aWFA#: PR#: Program Element: 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 or each cumulative container product ❑ Tank (2820) ontainers (2821) #of Containers: TA#: (>250 gallons) (>55 g ns and<250 gallons) 1 Product Type: Total Capacity: gallons (per tank or cumulative for containers by p t type) Install Date: ❑ Tank(2820) ❑ Containers (28 #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) stall Date: ❑ Tank(2820) ❑ Containers (2821) #of Co tainers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product e: 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: 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 FTotal;Capacity for Site: gallons Comments: a tt/ CGWTCIP A 6 Mn_f EHD Inspector: Reviewed Date: Entered Date: C ' By Initiate u—p By Initial: EHD 28-01 01/16/08