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SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMEN'+�_,� %b00 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: u age of / Facility Address: City: Inspection Date: W / r✓G I 11��/ ST� tel- 3�".-OY FA#: PR#: Program l m7 " Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 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) 'D p 1 Product Type: ��C Total Capacity: '!�-o D gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 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 Q50 gallons) 3 Product Type: Total Capacity: gallons Install Date: (por 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 (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #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: S6 6 gallons Total Capacity for Site: d0 gallons Comments: L / 3 Zo G- l Ow-P EHD Inspector: Reviewed Date: Entered Date: Hy Initial: q,l'),.(jj By Initial: EHD 28-01 01/16/08