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SAN JOAQUIN COUNTY .NVIRONMENTAL HEALTH DEPARTMENT V00 East Main Street, Stockton,CA 95202-3029v Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM/ Facility Name: Page of CA D© c)S Facility Address: City: Inspec on Da e: Z P I ORT A �yT�m l! FA#: PR#: Prog am Eleirient.. j9433 1 At-z?q'3& -2O 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. ER/Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 2Q®� Product Type: 7JilQr,KJr� Total Capacity: gallons (per 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: ®TESJC Total Capacity: 1 0 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: o p c gallons Total Capacity for Site: -3(100 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: ✓ y By Initial: 11-a'Q-pKj By Initial: !! EHD 28-01 01/16/08