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SAN JOAQUIN COUNTY `/ENVIRONMENTAL HEALTH DEPARTMENh..W 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 Nsme: V '(v G �s Page—j—of Facility Address: City: Inspection D te: FA#: PR#: Program Elgtn pl: DJr 1 GbG ( Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >: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: 4 T #: (>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: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 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) 3 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) 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<250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 00D gallons Total Capacity for Site: 00 gallons Continents: 2� 6-MIOWD EHD Inspector: Reviewed Daw Entered Date: V By Initial: rj,/ By Initial: er D� EHD 28-01 01/16/08