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- SAN JOAQUIN COUNTY i ENVIRONMENTAL HEALTH DEPARTMEN' a 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: P � Page � of i vufil &M I Facility Address: InspectionDa FA#: PR#: Program E t: / 5 © L 0 Tank/Container Information Complete for 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. ank(2820) ❑ Containers (2821) #of Containers: TA#: Q / 7� (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: To 0 gallons (per tank or cumulative for containers by product type) Install Date: IV/ank(2820) ❑ Containers (2821) #of Containers: TA,#: 0 —1 �o (>250 gallons) (>55 gallons and<250 gallons) 2Product Type: Total Capacity: V e? gallons (per tank or cumulative for containers by product type) Install Date: W/ank(2820) ❑ Containers (2821) #of Containers: TA#: �d In >250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for 6ontainerby'product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) � 4 Product Type: Total Capacity: f D d 6 gallons (per tank or cumulative for containers by product type) Install Date: ank(2820) ❑ Containers (2821) #of Containers: TA#: 7(p (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons a Install Date: tl (per tank or cumulative for containers by product type) --- Total Capacity this Page: ,jUX/ gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: ��'11, By Initial: 2 Dg EHD 28-01 01/16/08