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SAN JOAQUIN COUNTY •, ENVIRONMENTAL HEALTH DEPARTME o00 East Main Street, Stockton,CA 95202-3u.5, Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: �-� oz- ' 1JF �1�� i✓L Page of Facility Address: City: Inspection Dat FA#: PR#: Program 1 ment: Tank/Container Information Complete for all sites with cumul ive aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. Co ete one ox for each tank ach cumulative container product type. ❑ Tank(28 0) ntai r 2821) #of ntai A (>250 gallons) ga Ions <25 allons) 1 Prod e: v t Total Capaci g (per tank or cumulativ r containers by product type) Install Date: El Tank (2820) Ez Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Lyl� Total Capacity: '2—SO 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) 4 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) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: •a© gallons Total Capacity for Site: 2, ,rS"� gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: {� EHD 28-01 C a� 01/16/08