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SAN JOAQUIN COUNTY, s ENVIRONMENTAL HEALTHDEPARTMENt .'' 600 East Main Street, Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web.www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM ABOVEGROUND Facility Name: C l r r r/'.4 C-/ W,4 ren i rZr A r tVr ,1r'; &O&L S Page J_of Facility Address: City: Inspect' Date 2l '` FA#: PR#': Prograni Element: o5as� e2 Tank/Container Information Complete or 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: ,T (>250 gallons) (>55 gallons and<250 gallons) 1 � Product Type: Total Capacity: 1000 gallons (perltank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #;of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 2 Product Type: Total Capacity: gallons Install Date: {perltank or cumulative for containers by product type) 1 ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 3 i Product Type: Total Capacity: . gallons (per:tank or cumulative for containers by product type) Install Date' ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>2$0 gallons) (>55 gallons and<250 gallons) 4 ; Product Type: Total Capacity: gallons. (per',tank or cumulative for containers by product type) Install Date: r F ❑ Tank(2820)', ❑ Containers (2821) #of Containers: TA#: (>2S0 gallons) (>55 gallons and X250 gallons) 5 Product Type:. Total Capacity: gallons (per.tank or cumulative for.containers by product type) Install Date' • :r Total Capacity this Page: gallons Total Capacity for Site: ©jj gallons Comments: EHD Inspector: r Reviewed Date: ,` Entered Date: By Initial: 's6' By Initial. tj EHD 28-01 01/16/08