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SAN JOAQUIN COUNTY &ENVIRONMENTAL HEALTH DEPARTMEN'.& 00 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: Page 2— of Facility Address: City: Inspect' n Da 4/� / FA#: PR#: ProgramElement: 8 -;?� 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 type. EV'T'ank (2820) ❑ Containers (2821) #of Containers: TA#: /L9 6-17/,7 S' (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: '' (J twsrC/ O Total Capacity: /j94242 gallons (per tank or cumulative m-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 (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<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: C)0 0 gallons Total Capacity for Site: 22cl C�5 gallons Comments: o `W # cP EHD Inspectac _ (L. i — Reviewed J Date: Entered - Date: l/�� `l By initial: By Initial: Q' EHD 28-01 O 01/16/08