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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMF 600 East Main Street,Stockton,CA 95202-3%,- Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of Facility Address: W�y 9 9 City: Inspectio a e: o� FA#: PR#: Program ement: OOpOZZ9 /Jr 2. � Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 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#: &7 71-2 1 (>250 gallons) (>55 gallons and<250 gallons) Type: Product T e: Total Capacity: /000 gallons (per tank or cumulative for containers by product type) Install Dat--. Ml'<nk(2820) ❑ Containers (2821) #of Containers: 'i A#: QJ Ilk -7-7 (>250 gallons) (>55 gallons and<250 gallons) 2 /D�d Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and 450 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Dat':: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product i yF: 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 (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 210 0z) gallons Total Capacity for Site: ZO 6 gallons Comments: EHD Inspector: ) Reviewed Date:� Entered Date: By Initial: vv By Initial: D EHD 28-01 01/16/08