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SAN JOAQUIN COUNTY iNVIRONMENTAL HEALTH DEPARTMENT ""660 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- Page am Page , of Facility Address: City: Inspection Dte: SAmo- 010- l ANrEG� lI 1 $ bI FA#: rPR#: Program Element: 6gi3 a3 -2- 8 0 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 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#: 1 (>250 gallons) (>55 gallons and<250 gallons) O n , Product Type: ✓-`--w�_�n Y—/ Total Capacity: 3 O D 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) 2 Product Type: Total Capacity: � 0 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: gallons Total Capacity for Site: 7H gallons Comments: EHD Inspector: /� Reviewed Date: Entered Date V By Initial: tntlj lI•)-0-0� By Initiate 102 1 � zQ/D EI-1132"l 01/16/08