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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN . , �J 600 East Main Street, Stockton, CA 95202-3029 t3 / Telephone: (209) 468-3420 Fax: (209) 468-3433 Weh: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: �� � Page of Facility Addressc, �� City: � -)�"qC'Y Inspect on ate: �/2 w•G�r� FA #: do) 0 9 4 2 PR #: S'-/ Program Eleme Tank/Confiner Information etroleum _ 1320 gallons in tanks and ntainers over 55 gallons. Complete for all sites with cumulative aboveground storage o > Complete one box for each tank or ea h cumulative container product t ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 1 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 2 Product Type: Total Capacity: gallons Install Date• (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821)Xnstal ainers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 3 ype: Total Capacity: gallons te: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (/hs #of Contai rs: TA#: (>250 gallons) (>55 gallons and <250 4 Product Type. Total Capacity: g(per Date: tank or cumulative for containers by productInstall ❑ Tank (2820) ❑ Containe (2821) #of Containers:TA#: (>250 gallons) (>55 gallons an <250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons FTotal Capacity for Site: gallons Comments: EHD Inspecto . / Reviewed Date: By Initial: Entered Date: By Initial: /� 0 EHD 28-01 01/16/08