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` SAN JOAQUIN COUN'T'Y - ENVIRONMENTAL HEALTH DEPARTMENT' '*s./600 East Main Street,Stockton,CA 9521- .Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM FacilityName: ' Lr S� �O 4 , ! g� Page Of I City: Inspection GatFacility Addr s �f/I�.�('I N U PR#: Programs E amen O Tank/Container Information Comp for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. Comydete one box for each tank or each cumulative container product type. 11 Tank(2820) @kontainers (2821) #of Containers: #: „(>250 gallons) (>55 gallons and<250 gallons) 1Product Type: Total Capacity: 2 gallons Install Date:. (per tank or cumulative for containers by product type) r ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) 2 Product Type: 7. Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank 2820 ❑ Containers (2821 Tank(2820 ) Nof Containers: TA#: r (>250 gallons) (>55 gallons and<250 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 480 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers byproduct type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) r (>55 gallons and 480 gallons) 5 Product Type: . Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z/v gallons Total Capacity for Site: r 6 gallons Comments: V F 12 _ c4 : l { EHD Inspector: Reviewed Date: Entered. Date: By Initial: [�,y $ By Initial: EHD 28-01 01/16/08 r