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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN X600 East Main Street, Stockton,CA 95202-0e Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of CS v IVDS Facility Address: p' City: Inspection ate: 4/ J ' 161jQtDORT tyXST FA#: IPR#: Pragrani Element: S/ CSoSJ ZS Tank/Container Information Complete Pf 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 e. El"Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: .t Dn Total Capacity: /' D U D gallons Install Date: (per or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TA#: P,511,`(-�4� (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 6�4.f' Total Capacity: �/O O O 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 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>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: TA#: (>250 gallons) (>55 gallons and<250 gallons) g Product Type: Total Capacity: gallons (per tank or emulative for containers by product type) Install Date: Total Capacity this Page: ZC) 0 gallons Total Capacity for Site: (o gallons Comments: EHD Inspector Reviewed Date: Entered Date: GBy Initial: W tl By Initial: EHD 28-01 01/16/08