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SAN JOAQUIN COUNTY VIRONMENTAL HEALTH DEPARTMENT 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 Na e: O 6 Cr E ^r / S - of Facility Facility Address: City: Inspection Date: ZSZ 3 ,E•bvy 13 z /V Li' 2 17 FA #: do 1235b PR #: d515797 Program Eleme t: 2g 3l 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) Containers (2821) #of Containers: TA#: (>250 gallons) (> allons and <250 gallons) 1 Product Type: Total Capacity: gallons (per tank or cumulative for containers b roduct type) Install Date: ❑ Tank (2820) ❑ Container (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <25 gallons) 2 Product Type: Total Capacity: ga ns 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) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #o Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 Pro uct Type: Total Capacity: gallons Instal Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Con iners: TA#: (>250 gallons) (>55 gallons and <250 gallons) 5 Product T e: Total Capacity: gallons Install D (per tank or cumulative for containers by product type) Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: �' Al C � EHD Inspector: Reviewed By Initial: ' ate: Z' t Enter By Initial: Date: EHD 28-01 01/16/08