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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEt, j' 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 NamPage Of C N _ A Facility Address- City: Inspection Date: �q e � Z ��' g1lo FA#: R#: Program Element: I v o zgyK 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: T 1 (>250 gallons) (>55 gallons and<250 gallons) �� ---- {-0 n Product Type: Total Capacity: .3 gallons (per tank or cumulative for containers by product type) Install Date: ER/Tank (2820) ❑ Containers (2821) #of Containers: tTA#: (>250 gallons) (>55 gallons and<250 gallons) 2 5019Product Type: Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: /10 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) lristall Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 1 Total Capacity this Page: /,//0 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: � 1*, 61 _,,/.lA By Initial: EHD'_8-01 01/16/08