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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name: � � r� � S <br />Page ` of <br />Facility Address: <br />City: <br />L(JN <br />Inspection <br />— — <br />FA #: <br />FA4CJ5 <br />1'Ii #: <br />Program Element: <br />_Z83 ( <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum >:1,320 gallons in tanks* and containers**. <br />Complete one box for each tank or each cumulative container product type. <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 1 <br />5 aDv—Le <br />otal Capacity: gallons <br />4wM <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />l Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#:Ze 3 <br />2 <br />Product Type: U1J�� <br />Total Capacity: W gallons <br />(per tank or cumulative for c ntainers by product type) <br />Install Date: 1196 <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />4 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: <br />gallons <br />Total Capacity for Site: �� gallons <br />Comments: <br />EHD Inspector: <br />Reviewed n Date: <br />By Initial: 1 C(� <br />$ 13 <br />Entered <br />By Initial: <br />Datc: <br />f !J <br />*Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br />**Container means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 <br />