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SAN JOAQUIN COUINTY ` NV IRONMENTAL HEALTH DEPARTMENT 0 East Main Street,Stockton,CA 95202-3029 f Telephone:(209)468=3420-Fax.(209)468-3433 Web:www;sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / 1 14 = /L .SF14 V G Page of. Facility Address: 4. City; Inspection Date- ateFAFA #: PR#: Program Element: 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 pduettype. I` Tank (282 ers 2821 ( ( } #of.Containers: TA#- (>250 gallons) (>55 gallons and<250 ga o 1 Pro uc Total Capacity: -TC1 D gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ 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) ❑ Containers.(282 1)'. #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:- El ate:❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 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: Total Capacity: gallons f (per tank or cumulative for.containers.by product.type) Install Date: 14, Total Capacity this Page: gallons Total Capacity for Site: d gallons Comments: l � N EHD Inspector: Reviewed Date: z Entered _ Date: By Initial: C(. fj.0� By Initial: CY �j EHD28-01 ry t3 1! 01/16/08