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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN' 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: o' i'i (IIPS-- Page 3 of _ Facility Address: � City: Inspection Date: �0 5� �� Cfl'/G✓y �j( y L G FA#: PR#: Program lem t: 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) Ercontainers (2821) #of Containers: _� TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 57,3' gallons (per tank or cumulative for containers by product type) Install Date: [1 Tank (2820) Containers (2821) #of Containers: TAM 2 (>250 gallons) (>55 gallons and<250 gallons) d Product Type: Total Capacity: &'9 0 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: J gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: C✓ By Initial: By Initial: kv EHD 28-01 01/16/08