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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMET 600 East Main Street, Stockton, CA 95202-30zv Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility e: G X7ri r Page of U 0 Facility Address: _ City: = Inspection Date: Zd () l&go 5-29,G FA #: PR # 7 Program ement: C) d o 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#: (>2 ns) (>55 gallons and <250 gallons) 1 Product Type: Total Capaci gallons Install Date: (per tank or cumulativ or containers by product type) ElTank (2820) ❑ ntainers (2821) #of Containers: TA#: (>250 gallons) (>55 gal sand <250 gallons) 2 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by pro ct type) ❑ Tank (2820) ❑ Containers (28 ) #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) #of ontainers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 Produc Type: Total Capacity: gallons Install Da (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 Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons FTotal Capacity for Site: gallons Comments: 6 47 T?;::'-" EHD Inspector: ✓ Reviewed 1 Date: By Initial: c . tJ r; 1�0 D� Entered Date: By Initial: EHD 28-01 01/16/08