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SAN JOAQUIN COUNTY ?NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 1 f Page of Facility Address: City: Inspection Date: FA#: PR#: Program Element: D p Z d 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) ❑ Containers (2821) #of Containers: TA#• - (>250 gallons) (>55 gallons and<250 gallons) / 1 Product Type: Total Capacity: 0 V gallons (per tank or cumulative for containers by product type) Install Date: L,J/Tank(2820) ❑ Containers(2821) #of Containers: ''A#• d51 7 Lr'q (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: It, 60 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) Mall 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: gallons Total Capacity for Site: Ca gallons Comments: EHD Inspector: Reviewed Date: �/ Entered I� Date: By Initial: \Atj dJ�.O 0 By Initial: (/ EHD 28-01 01/16/08