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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME' ' 600 East Main Street,.Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.0rg/e8d ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM t ,n C o 'rI`/E'l�G IOW r klLcW 5. Page_�of � acil�52 AddFes City: Inspection Date: - le 14tw C/f 5-11 19 0J7 FAR: PR#: Program lement: r o o �3 /1 Tank/Conta' er Information Complete for all sites with cumulative aboveground storage of petroleum 2:1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. IR/Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: -- - Total Capacity: d O, gallons (per tank or cumulative for containers by product type) Install Date: ;-5;�4ank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) .(>55 gallons and<Z50 gallons) 2 Product Type- Total Capacity: ,rO f7 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 H 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: 6 0 0 gallons Comments: Z D 4UO&A3 EHD Inspector: Reviewed Dater Entered Date: C y By Initial: J �,'rjti o�6 By Initial: EHD 28-01 crc 01/16/08 1 i