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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 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 Name: C Page_of Facility Address: City: Inspect'on Dat I 3 Gv o ' FA#:.. PR#: Program Element: O �7 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) 1:1 Containers (2821) #of Containers: TA#: �Q�l wg-LI1 g (>250 gallons) (>55 gallons and<250 gallons) n 1 Product Type: r ,1 Total Capacity: L 00 allons (per tank or cumulative for co mers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: 66Dq gallons (per tank or cumulative fo containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: TA#: h//�o2�j (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: O'/ Total Capacity: 1 ! b gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) f�ontainers (2821) #of Containers: TA#: f4 er (>250 gallons) (>55 gallons and<250 gallons) ' / 4 Product Type: 17 y�/zo Total Capacity: ,�,� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Vcontainers (282 1) #of Containers: _� TA#: 2 (>250 gallons) (>55 gallons and<250 gallons) r 5Product Type: 9 D k,/ D Total Capacity: -� gallons � (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: U Z� gallons i Total Capacity for Site: `O Z0 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: W V (�.`� a By Initial: EHD 28-01 01/16/08