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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMI0 600 East Main Street,Stockton,CA 95202-302 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: JLlG� Page Z of 7� Facility Address: City: Inspection Date: FA#: PR#: Program Element: 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 type. ank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 07C (✓ Total Capacity: /U O o gallons (per tank or cumulative for containers by product type) Install Date: 52"'Tank(2820) ❑ Containers (2821) #of Containers: TA#: Q�j [py�Jo2 (>250 gallons) (>55 gallons and<250 gallons) _ 2 Product Type:Total (per tank orpcumulaattive for containers ct type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 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) 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 Install Date: (per tank or cumulative for containers by product type) _..- Total Capacity this Page: gallons 'Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: C, By Initial: By Initial: /„ EHD 28-01 t.r 01/16/08