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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN'. 600 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 of Facility Address: S7 9 City: Inspectio Date: FA #: PR #: Program Element: oC)o d o815 ov 2 �� 7-- Tank/Container 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) #of Containers: TA#: Q, -f j j $3 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: �4/< !q V "-f- A S Total Capacity: 2, y gallons Install Date: /< (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: b? / fv © 87f 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: -L1`,G %— Total Capacity: /0 O O b gallons lontainers Install Date: (per tank or cumulative for byproduct type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM (>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: 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 Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: Q 0 U gallons Total Capacity for Site: 2 Z D G 6 gallons Comments: EHD Inspector: C . Reviewed By Initial: Date: Entered Date: By Initial: ke VAT AT EHD 28-01 01/16/08