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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: 7/ Page --�— of Facility Address: Inspection Date: FA #: PR #: Program Element: 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#: Qom/ 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: T�Ci�OI✓ Total Capacity: 8 4 6 0 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 19 l 150 (>250 gallons) (>55 gallons and <250 gallons) 2 Product Type: Total Capacity: Z 312 2, gallons (peror cumulative for ontain by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: s � . Y/ 2-57 Total Capacity: l 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) 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 rTotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: By Initial: Entered Date: By Initial: �L?B� EHD 28-01 01/16/08