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SAN JOAQUIN COUNTY ' t IENvIRONMENTAL HEALTH DEPARTMEM 00 East Main Street,Stockton,CA 95202-30 t Telephone:(209)468-3420'Fax:(209)468-3433 Wei:www.sjgov.org/ehd. ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY:FORM Facility Name: / s Page_ of Facility Address: City: Inspection Date: At TA FA#: ` PR#: Program Element: 06 Tank/Container Information' Complete for all sites with cumulative aboveground storage ofpetroleum L>1320 al ns in tanks and containers over 55 gallons. Co fete one box for each tank or each cuml.il tain oduct ❑ Tank(2820) Containers (2821) #of Contai ers: = TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 150 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) 2 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) r ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM f (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity:, gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #af Containers:_#.. . TA#: (>250 gallons) '(>55 gallons and 450 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 typej Install Date: Total Capacity this Page: S`Q gallons Total Capacityfor Site: 0 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: q L EHD 28-01 01/16/08