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SAN JOAQUIN COUNTY t WIRONMENTAL HEALTH DEPARTMENT ., j 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: �-. �� / Page of 4-- 1 Facility Address: City: Inspection Date: FA#: PR#: Program Element: C-> �2-il -31 2-153-2" Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. Co5eete one box for each tank or each cumulative container product type. ❑ Tank(2820) Containers (2821) #of Containers: A TA#: (>250 gallons) (>55 gallons and<250 gallons) r ZZ / / Product Type: S 7 0 y Total Capacity: d gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: -C6 azo le- 2 (>250 gallons) (>55 gallons and<250 gallons) Product Type: Total Capacity: )Orp 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: TAM (>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 Total Capacity for Site: gallons Comments: . a EHD In r: Reviewed Date: Entered Dat . By Initial: By Initial: r EH 8-01 01/16/08