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H SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH.DEPARTMEN- 600 East Main Street, Stockton;CA 95202-3 Telephone.(209)468=3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVKYTORM Facility Name: D LA T /L 0 -o f r W Page of Facility Address: rCity Ins pe t on Dat . FA#: PR#: Q -. Progta le nt: Tank/Container Information �� lT J` Complete r 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) ❑ Containers (2821) #of Containers: TA (>250 gallons) (>55 gallons and 450 gallons) Total Capacity: .SOB gallons .Product Type: (per tank or cumulative for containers byproduct type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#. (>250 gallons) (>55 gallons and 450 gallons) 2 Product Type:. Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2 821) #of Containers:' TA#: (>250 gallons) .(>55 gallons and 450 gallons) 3 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 450 gallons) 4 Product Type: 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 X250 gallons). 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) { Total Capacity this Page: e gallons Total Capacity for Site: gallons Comments: „ A aN� EHD Inspector: Reviewed Date: E�tered By Initial: +��p.p B Initial: LL_iiff!! EHD 28-01 - a 01/16/08 4