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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN' .,00 East Main Street,Stockton,CA 95202-30. Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page Z of Facility Address: City: Inspection ate: FA#: PR#: Program Element: ata) Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) E<Containers (2821) #of Containers: ;?--� TA#: ��(Q$ (>250 gallons) (>55 gallons and<250 gallons) / 1 j l. Product Type: Total Capacity: - gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) CYContainers (2821) #of Containers: �_ TA#: i9,5—`IF (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: ,'old D �'d19i 1-1L Total Capacity: / r6 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) E Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: / Z 6) 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: I- ' gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: "7 EHD 28-01 01/16/08