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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN' 600 East Main Street, Stockton,CA 95202-3027 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility e: !!� I C P T�I �14 Page__L of Facility Address: City: Inspecti n D t . 17 191 A vf./V v�r 5 C'A 0 1� t� FA#: PR#: Program Element: W / 65ag2,q 7 �fl�o 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. Tank (2820) ❑ Containers (2821) #of Containers: TA_ #: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: FWr Total Capacity: � 0 a gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: T�A,�: (>250 gallons) (>55 gallons and<250 gallons) p j v 2 Product Type: _X .D' Total Capacity: 190 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: gallons Total Capacity for Site: gallons Comments: v EHD Inspector: /� Reviewed Date: Entered Date: `�/�j By Initial: �� f1,�-(� By Initial: 1� EHD 28-01 / 01/16/08