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SAN JOAQUIN COUNTY-f ENVIRONMENTAL HEALTH DEPARTMENIL # 600 East Main Street,Stockton,CA 95202-3029 . a Telephoner(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ' ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM- Facility Name: Page—/—of'--, Facility Address: City: Inspection Date: FA#: P12#: Program Element: /�A 000 0 7- 51c L� Tank/Con" tainer Information Complete for all sites with cumulative aboveground storage of petroleum 2t1320 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#: � (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: �'0 o gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 2 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) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM (>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 Install Date: (per tank or cumulative for containers by product type) _ Total Capacity this Page: gallons Total Capacity for Site: gallons: Comments: k EHD Inspector: Reviewed Date: Entered Date: r By Initial: By Initial: EHD 28-01 r 01/16/08