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SAN JOAQUIN COUNTY y _ - ENVIRONMENTAL HEALTH DEPARTMENT y 'Ni,_ 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- IN � Page . / of / Facility Address: City: Inspect' n Date- 10 ate• G 0 L i�l'i � �'f� . a8 FA#: PR#: Program Element: 23 6�a� �� -z-s 40 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Com tete one box for each tank or each cumulative container product type. ❑ Tank(2820) ontainers (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) CQ'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) (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: y1 Total Capacity: gallons 1-7 Install Date: (per tank or cumulative for costa by product type) j El Tank 2820 PIcontainers 2821 ' Tank(2820) ( ) #of Containers: �_ TA#: (>250 gallons) (>55 gallons and X250 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) Containers (2821) #of Containers: TA#: . (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: .—Gvi 5'767` 0 . Total Capacity: 2 jj"7 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: if Lf(,7 gallons Total Capacity for Site: ?7 D gallons Comments: ��(��G �i/p Tisk .Eri-, EHD Inspector: ^ Reviewed Date: Entered Date: / By Initial: 11_ By Initial EHD 28-01 v [ 01116!08 . r