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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street, Stockton,CA 95202-3Oz9 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: ,l r / L L�✓ G X fi g ss Page of Facility Address: City: Inspection Date: f ss pl D FA#: PR#: ✓ Program El men o D o3 2 .SIS / 2$ 3 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. E "Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 1 D O ° v gallons (per tank or cumulative for containers by product type) Install Date: Its' Tank(2820) ❑ Containers (2821) #of Containers: TAM OJT/ (>250 gallons) (>55 gallons and<2 lions) 2 _` Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: R/Tank(2820) ❑ Containers(2821) #of Containers: TA# (>250 gallons) (>55 gallons and<250 gallons) 3 d Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ontainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons.and<250 gallons) 4 60 Product . - 9 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) 5Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 1 f- gallons Total Capacity for Site: gallons Comments: MA W SavW Ta I� U v / o &SIX,26i, EHD Inspector: Reviewed I Date: Entered Date: a ho By Initial: 'n�J G)�(1 a t By Initial: l EHD 28-01 01/16/08