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SAN JOAQUIN COUNTY 7NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax (209) 468-3433 Web: www.sjl ABOVEGROUND PETROLEUM STORAGE PROGPIAM SURVEY FORM Facility Name: Page of Facility Addr City: Inspection Date: FA #: PR #: Program Element: Tank/Container Inforotion Complete for all sit\esh cumulative aboveground storage of petroleum,& 1320 gallons in tanks and containers over 55 gallons. om lete one box for each tank or each cu alive container product type. ❑ Tank (2820) ❑ ontainers (2821) #of Con tners: TA#: (>250 gallons) (>55 ns and Q50 gallons) 1 Produ Type: Total Capacity: gallons (per tank or cumulative for containers by kuct type) Inst Date: ❑ Tank (2820) ❑ Containers 821) f Containers: TA#: (>250 gallons) (>55 gallons and <250 g ns) 2 rotType: Tota] Capacity: gallon Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers/(2�82 # Containers: TA#: (>250 gallons) (>55 gallons and <253 Prod t Type: Total Capacity: Install e: (per tank or cumulative for containers by produ ❑ Tank (2820) ❑ Contain (2821) #of Containers: TA#: (>250 gallons) (>55 gallons an 50 gallons) 4 Product Type: Total Capacity. gallons Install Date: (per tank or cumulative for containers product type) ❑ Tank (2820)Intamm iners (2821) #of Containers: TA . (>250 gallons) and <250 gallons) 5 Product Type: e, Total Capacity:gallons Install Date: (per tank or cumulativproduct type) Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspect : Reviewed Date: Entered Date: By Initial: By Initial: EHD 2"1 01/16/08