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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN" o00 East Main Street, Stockton, CA 95202-302> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: n 7" V v c -K b V/ t-� Page Y of Facility Address: City: Inspecti Date: � /v Y/' FA #: PR #: Program Element: Do - 52- Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_ 1320 gallons in tanks and containers over 55 gallons. Com to one box for each tank or each cumulative container product type. 11 Tank (2820) 1,15ontainers (2821) #of Containers: TA#: i9,51 % VC) (>250 gallons) (>55 gallons and <250 gallons) 1 Total Capacity: Z b 0 Product Type: gallons Install Date: (per r cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: '% 0o -0 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) 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: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: 48/f) EHD 28-01 01/16/08