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SAN JOAQUIN COUNTY ,NVIRONMENTAL HEALTH DEPARTMEI ` v%)O East Main Street,Stockton,CA 95202-30i-g Telephone:(209)468-3420 Fax.(209)468-3433 Weh:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: y�/ p G Page_ of Facility - Facility Address: City: InspectioA Date: FA#: PR#: P Progr m Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ❑ Tank 2820 ontainers 2821 ( ) ( ) #of Containers:_= (>250 gallons) (>55 gallons and<250 gallons) 1 Total Capacity: Product Type: � Mons (per tank or cumulative f - ' ers by product type) Install Date: ❑ Tank (2820) containers (2821) #of Containers: _� TA#: 3 (>250 gallons) (>55 gallons and<250 gallons) , 2 Product Type: ( -, 42 4 Total Capacity: S gallons (per tank or cumulati containers by product type) Install Date: Q Tank(2820) 04-C"ontainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 31— Product Type: p / Total Capacity: gallons Install Date: (per tank or cu or conta' by product type) ❑ Tank (282 Contail s (2 21) #of- tainers: (>250 gallons) (>5 all an 0 gallons)- 4 rod t e: Total Capacity: ga s (per tank or cumulative for containers by product type) Ins Date: ❑ 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: gallons TTotal Capacity for Site: gallons Comments: Vj/ `e II h f- EHD Inspector: / Reviewed Date: Entered D te: i/ By Initial: By Initial: EHD 28-01 d 01/16/08