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SAN JOAQUIN COUNTY `,..rBNV1R0NMENTAL HEALTH DEPART'METr,.,./ 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 SSC �'�e Li G I�/o UTrL: T r,L � NTS Facility Address: City: Inspection D e: g C' L r7't'1 Nrs f2 d FA#: PR#: Program Elemen O 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: tTA#: (>250 gallons) (>55 gallons and<250 gallons) 1 PTOC1UCt Type: / Total Capacity: 0 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 gafons) 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: TA#: ( 250 gallons) (>55 gallons and<250 gallons) q. 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) � Product Type: Total Capacity: gallons (per tank or cumulative for containL s by product type) install Date' Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: t EHD Inspector; Reviewed Date: Entered Date By Initial: l p,� ��..t�.0� By Initial: � a� EHD 28-01 01/16/08