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SAN JOAQUIN COUNTY _ iNVIRONMENTAL HEALTH DEPARTMEN "500 East Main Street, Stockton,CA 95202-302r°' Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: --jQS Page of / Favi t Address: City: Inspection D te: 6 S a . T W r G Zc o FA#: PR#: Program a ent: /16`77 e z o Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) I ProductType:e: 6 S D U YX � YP Total Capacity: / gallons (per tank or cumulative for containers by product type) Install Date: EkITank (2820) ❑ Containers (2821) #of Containers: TA#: A (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: �� Total Capacity: 7, 0-0 gallons (per tank or cumulative for containers by product type) Install Date: T (2820) ❑ Containers (2821) #of Containers: TA#: p (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: Z-�� gallons �r (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) 4 Product Type: Total Capacity: 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) 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: gallons Comments: EHD Inspector: Reviewed1 Date: Entered Date: By Initial VVWt�/"`"""„I By Initial: EHD 28-01 01/16/08