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SAN JOAQUIN COUNTY ?NVIRONMENTAL HEALTH DEPARTMENT.,W '500 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: p U Q/� -5 IN Page of Facility Address: City: Inspection Date: 2. d G SI -/0 FA#: PR#: Program Element: O 173 2. 7 - .>n Tank/Container Information Complete for 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 type. Pr'Tank (2820) ❑ Containers (282 1) #of Containers: TA#: _ % g 7 (>250 gallons) (>55 gallons and<250 gallons) Type: o`i^ 1 Total Capacity: /D O n gallons Product T (per tank or cumulative for containers by product type) Install Date: C�Yfank(2820) ❑ Containers (2821) #of Containers: . TA*: (>250 gallons) (>55 gallons and<250 gallons) 2 ,Sp,� Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: n A eAA (>2n gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: 30-6 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: TA#: D (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Al til p I!Z , eq 1 Total Capacity: // 0 gallons (per tank or cumulative for containers by product type) Install Date: ® Tank(2820) D-Containers (2821) #of Containers: 3 TA#: (>250 gallons) (>55 gallons and<250 gallons) 5Product Type: 141 Total Capacity: �6 J gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: zo?r gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: kXA y,Cl, 01 By Initial: D EHD 28-01 01/16/08