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- SAN JOAQUIN COUNTY 'NVIRONMENTAL HEALTH DEPARTMEN -. 600 East Main Street,Stockton,CA 95202-3 ' Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: /:,z p ,�✓ Page of r Facility Address- City: Inspectio Date- FA#: PR#: Pra&rarn Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2,1320 gallons in tanks and containers over 55 gallons. Cam Pkte one box for each tank or each cumulative containerroduct ❑ Tank(28 sofa s 2821) #of Containers: TA#: .d�`Z � �4 (>250 gallons) (>55 gallons and<250 gal ansS -1 1 Pro uc L. Total Capacity: ..2'�LD gallons (per tank or cumulative for containers by product type) Install Date: . !s• i Tank (2820) 0 Containers (2821). #of Containers: TA#: (>250 gallons) (>55 gallons and X150 gallons)_ Product Type: �D Total Caacity: �-` gaons Install Date: (per r cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TA d6/ -7 LI-00 (>250 gallons) (>55 gallons and<250 gallons 3 Product Type: �J'7- Total Capacity: b ga Ions (per tank or cumulative for containers by product type) Install Date: i 0 ontainers (2821) #of Containers: TA#: jo, -7 C2,0 ons) > llonsaa Q50 gallons) Total Capacity. . gallons (per tank or cumulative for containers by product type) Install Date: -sin 820) t] Containers (2821) #of Containers: TAM (>250 gallons) Ballo d 450 gallons) 9 5 P4oduct T. e: Total Capacity: gallons z (per tank or cumulative for containers by product type) Install Date:. Total Capacity this LNjZE&= gallons Total Capacity for Site: gallons . Comments: ' t EHD Inspector: I Reviewed Date: Entered Date: By Initial: By Initial: EHL?28-01 01/16/08