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SAN JOAQUIN COUNTY iLIVIRONMENTAL HEALTH DEPARTMEN^ "600 East Main Street,Stockton,CA 95202-302V"" Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: a rV IW a >R T.l D page�_of Facility Address: V City, Inspection ate: z lam- j2/S` o FA#: PR#: Program Element- 2- Tank/Container lement:2Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) Total Capacity: / 8 dy0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) E Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) ----- Total Capacity: 'A�s gall (pr tank or cumulative for containers by product type 19eTank (2820) ❑ Containers (282 OTA#: (>250 gallons) (>55 gallons and<250 galloi 3 �U Total Capacity: -allot (per tank or cumulative�orcoriitainers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TA#: 1,00 (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: //i4 S 25 Total Capacity_•.—SU D gallons (peke dative 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: gallons Total Capacity for Site: 6 gallons Comments: -X- nz9 EHD Inspector: Reviewed Date: Entered Date:By Initial: Q.fy O� By Initial r� EHD 28-01 O 01/16/08