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SAN JOAQUIN COUNTY . ENVIRONMENTAL HEALTH DEPARTM 600 East Main Street,Stockton,CA 95202- 9 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page z- of Facility Address: City: InsVn P FA#: PR Program El menta 13 � o a Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. ConJiAete one box for each tank or each cumulative container product e. ❑ Tank(2820) Containers (2821) It atners: TA#: (>250 gallons) (>55 gallons and Q5 1 Product Type: USS® Total Capaci gallons (per cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 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<250 gallons) 3 Product Type: Total Capacity: 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<250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers byproduct type) Install Date: — Total Capacity this Page: 2---Oe) gallons Total Capacity for Site: gallons Comments: /f GZ EHD Inspector: Reviewed Date: Entered /1 Date: By Initial: By initial: t./t/ 7 8 EHD 28-01 l•` L 01/16/08