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SAN JOAQUIN COUNTY ;NVIRONMENTAL HEALTH DEPARTMENT ,.00 East Main Street, Stockton, CA 95202-302y Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C' j') L S T j 1! S t 4 L p► U .5' Page , of I , Facility Address: 2s z v STA N S tqS City: ST ST 2V/-2-1 Inspecti n Date: f Prograin Element: FA #: © n �Q �j PR #: 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#:�l 7 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: / C o 0 gallons Install Date: (per tank or cumulative for containers by product type) LY/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 7 ( 8e�) ' 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type:_ 0-X", Total Capacity: /000 gallons o (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: Z o o O gallons Fotal Capacity for Site: Z U 0 gallons Comments: EHD Inspector: /17Reviewed By Initial: Date: Q, tiS Entered Date: By Initial: g EHD 28-01 01/16/08