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SAN JOAQUIN COUNTY ANVIRONMENTAL HEALTH DEPARTM East Main Street,Stockton,CA 95202-3 9 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: a q 14//9/9,0 31V a Page of?/ Facility Address: City: Inspection Date: FA#: PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. C mplete one box for each tank or each cumulative container product type. ❑ Tank(2820) ainers (2821) #of Containers: _� TA#: N67 (>250 gallons) 55 gallons and<250 gallons) 1 Product Type: C2 r l� Total Capacity: ZoD 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) 2 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) 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: 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: 7,6',h9 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed -6a^` te: Entered ) Date:/ By Initial: w'V ��(,'u By Initial: (� � EHD 28-01 01/16/08