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SAN TOAQUIN COUNTY ,..,,ENVIRONMENTAL HEALTH DEPARTMEN7�r 600 East Main Street, Stockton,CA 95202-302T Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM FaciOty me: E G ©/[ C/1 T Page of Facility Add s: ty: Inspection Date: / �3 6 Gr�pCf✓ Fes#: PR#: Program Element: O 2 O 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 Tank(2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) l Product Type: y/-A S Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallon wd Qin—i,- 2Product Type: p Total Capacity: � Sid _gallons talld (per tank or cumulative for conmmers by product type) Install Date: Tank(2820) ❑ Containers(2821) #of Containers: TA#: (>2s0 gallons) (>55 gallons and Q50^^" 3 Product Type: Total Capacity:_ 0 _gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) 4 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 Q50 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 Comments: EHD Inspector: Reviewed1 Date: Entered Date: C' By Initial: 1 t .T.1 t r�,"!/,0� By initial: I EHD 28-01 WWW 01/16/08