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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM 600 East Main Street, Stockton,CA 95202--)vi9 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name. Page of J V 5. /C Lf Facility Address: City: Inspect' Date: c. X 0 FA#: PR#: Progra Element 00 /071 9 �7 �g3 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. Er"Tank (2820) ❑ Containers (2821) #of Containers: TA#: �/ (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: j!' A S Total Capacity: 1.06 D gallons (per tank or cumulative for containers by product type) Install Date: Ly' Tank(2820) El Containers (2821) #of Containers: TA#: / 3 (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: D/10113',K Total Capacity: 1 0 0 e) gallons Install Date: (per tank or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) O ` 3 Product Type: IZZ4 S T� Total Capacity: 2''7 S� gallons (per tank or cumulative for containers by product type) Install Date: l'Tank (2820) ❑ Containers (2821) #of Containers: TA#: l(e 7`15 (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: u o f Ll L Total Capacity: Z 7 gallons (per tank or cumulative for containers by product type) Install Date: fff/Tank (2820) ❑ Containers (2821) #of Containers: TA#: D5)&7L (>250 gallons) (>55 gallons and<250 gallons) 5Product Type: p l Total Capacity: '- 7 - – gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: Z, Z gallons Comments: EHD Inspector: , Reviewed Date: Entered Date: L ' By Initial: By Initial: EHD 28-01 01/16/08