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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN. o00 East Main Street, Stockton, CA 95202-3025 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: ,i Page 'y of Facility Address: City: Inspection Date: 2 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) TA#: 5j Ze ze 4, Q (>250 gallons) (>55 gallons an s O 1 Product Type: Total y: gallons er tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: (9 '1 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: M D Ac!/- 0/ Total Capacity: 00c) 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) f 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: h a B g 3 4 (> 50 gallons) (>55 gallons and <250 gallons) Product Type: ��a / O/ TopCapacity: gallons Install Date: (p 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: 43 Q gallons Total Capacity for Site: gallons Comments: EHD Inspector: _ _T Reviewed y� Date: By Initial: 2� V" 3 1 I Z Entered Dat4-1 By Initial: - v X EHD 28-01 01/16/08 01