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SAN JOAQUIN COUNTY g44ENVIRONMENTAL HEALTH DEP Rn 00 East Main Street, Stockton, CA 95202- 0 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Sf✓ j— 1�1L• ! Page 2— of Facilitv Address: City: Inspection Date: FA #: PR #: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Com Tete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers: TAM 51 Le Ole D (>250 gallons) (>55 gallons and <250 gallons) 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) ate:❑ Install Date.- 11Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 2 Product Type: Total Capacity: 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) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ank (2820) El Containers (2821) #of Containers: TA#: (> 0 gallons) (>55 gallons and <250 gallons) 4Product Type: T al Capacity: gallons Install Date: ( 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: 5 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered DaZzLd By Initial: By Initial: EHD 28-01 01/16/08