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SAN JOAQUIN COUNTY , ' ENVIRONMENTAL 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: 0 ! C/ T Y OF m A N T l`: C Page / of ) Facility Address: City: Inspection ate: o °� W. C'E�vrrZ A S T ntu nr c-A l 6 FA#: PR#: Program lement: c7o 1 z3 o 6 1 S'/S-?/ -0 0 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: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1% (>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: #: V (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons VQ (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: OL zoo gzf`r �3s'� ' �zr=zrz8 z 2r 8d1 EHD Inspector: Reviewed ( Date: v Entered Dat By Initial: By Initial: EHD 28-01 01/16/08