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SAN JOAQUIN COUNTY { kw�INVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202=3029 . Telephone:(209)468-3420 Fax:(209)468-3433 Web:_www.sjgoy,org/ehd ABOVEGROUND PETROLEUM STORAGE.PROGRAM SURVEY FORM Facility Name: ik1Ul S Page j of Facility Address: City:. Inspection Date: FA#: PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2�1320 gallons in tanks and containers over 55 gallons. Com lete one box for each tank or each cumulative container product type. Tank(2820) ❑ Containers (282 1) , " ` #of Containers: rte- �} TA.#-'. (>250 gallons) (>55 gallons and X250 gallons) 1 ,— Product Type: Total.rCapacity: OD gallons (per tank or cumulative for containers by product type): Install Date: PO Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55-gallons and<2M gallons) 2 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<250 gallons) 3 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<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: TAM .(>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: gallons_ Total Capacity for Site: :gallons Continents: EHD inspector: f) , —- Reviewed Date: Entered Date:/y /IM /J By Initial: By Initial: "C EIID 28-0 I