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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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: 'q � Page�_of / Facility Address: City: Inspection Date: FA#: PR#: Program Element: 0066 gl dsi god -2— elv Tank/C tainer Information Complete for all sites with cumulative aboveground s rage of petroleum >1320 gallons in tanks and containers over 55 gallons. Complete one box for ea tank or each cumulative container product type. ank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) - 1 Product Type: Total Capacity: ,S 6 z7 gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TAM t (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: /��eP�f Total Capacity: crO b gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 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) 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 (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: /00 V gallons Total Capacity for Site: gallons Comments: DT 0#L / KV-0 Y1, p EHD Inspector: Reviewed Entered Da By Initial: By Initial: I � D EHD 28-01 0l/l6/08