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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN'. o00 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: .S /q/SDS IAZE5T Page / of Facility A dress: City: Inspection Date: �, b CoSfIMA)�U Pfi (fAKt)5 PAI'�K 51X� FA#: PR#: Programylement: A9 1 o5a?6V_j'P 1 z. Tank/Container Information Complete pr 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: f�..t.P Total Capacity: 0 gallons (per tank or cumulative fortlIntainers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>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: TAM (>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: 5OD gallons Total Capacity for Site: �_fQ� gallons Comments: EHD Inspector: Reviewed Date: / Entered Date: By Initial: U'o C, (�-j`b By Initial: EHD 28-01 01/16/08