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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 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: O D O T / AIT C � 7- � .SAN1 TAIZ 7A T/O� Page of I Facility Address: �/ City: Inspectio Date, E Go�N�D� WWI /S /ql/3 /l FA#: PR#: Program Element: aoI ©6 W g5a a I Z 8 31 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. Ff"Tank(2820) ❑ Containers (2821) #of Containers: TAA: �5,7c3o2? (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAS: (>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 (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) $ Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 0 0 6 gallons Total Capacity for Site: 2 0 gallons Comments: EHD Inspector: e" Reviewed Date: Entered J /n Date: By Initial: By Initial: EHD 28-01 01/16/08