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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN,,.� X600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Far.(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / p LL/ S UGk1NG— Page of Facility Address: City: luspectio Date:, �. 0.56 r' • ADA A✓ ST�� /0 FA M PR M Program Element: S93 )5an qa ` 3" - 0 Tank/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: TAM (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 'L gallons Install Date: (per tank or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 2 ProductType: S "f!- O,, l� Total Capacity: Z\ 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 end Q50 gallons) q 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) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) - Total Capacity this Page: s24. S gallons Total Capacity for Site: gallons Comments: i %D / G /I S T xJ I.eI,rlr T T? J EHD Inspector: Reviewed Date: ./ Entered Date: By Initial: �d•�-Oyt By Initial: EHD 28-01 01/16/08