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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-302> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r ti �A f T _ At/ Page of Facility Address: City: Inspe do Date: Z�a 906 FA _ �p� PR#: — Program Element: OO 3 sQ�-t' "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. fi"Tank (2820) ❑ Containers (2821) #of Containers: T'A#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 1 D Lla 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:' *10 gallons (per tank or cumulative for containers by prod _� (>250 gallons) (>55 gallons and<250 gallons) n 3 Product Type: ,h� Total Capacity: V-O-D gallons (per tank or cumulative for containers by product type) Install Date: � ,�� Gam' � /✓�21q�QN ❑ 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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: S gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: �• By Initial: o-j 401°1-M By Initial: EHD 28-01 01/16/08