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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN' /Yy� ' $00 East Main Street, Stockton,CA 95202-3029'r �A/„uvl Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FdkM Facility Name: C Page of Facility Address: City: tnspec'on ate- o O S - FA#: PR#: Program Element: 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) ❑ Containers (2821) at#of Containers: TA#: lc'Da(p (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 0 Total Capacity: /boQ p gallons (per tank or cumulative for ntainers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: (//1/4yQ Total Capacity: / o o a gallons (per bunk 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 emulative for containers by product type) Install Date: Total Capacity this Page: POO gallons Total Capacity for Site: gallons Col!`A.f 5A7: t A EHD Inspector: Reviewed te: Entered Date: By Initial: By Initial: EHD 28-01 01/16/08