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SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMEN �0 East Main Street, Stockton,CA 95202-30'19"'-' Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page_L of Facility Address: Cny: inspect. Dat 383. 5-o S . J �� L1112 FA N. (��f I PR#• Program E mens: q y `FOCI t.1 •� i �" U 2 g 7 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. L Complete one box for each tank or each cumulative container product type. Id' 1'ank(2820) El Containers (2821) #of Containers: TA#: B rilCoD�� (>250 gallons) (>55 gallons and<250 gallons) t I Product Type: OZ�J Total Capacity: _, Q i&ffgallons (per tank or cumulative for c tainerso�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 (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 (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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comme T ^�� �1 C e'` EHD Inspector. Reviewed Date: X Entered Date: C. By Initial: By Initial: {t! EHD 2M I 01/16108