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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMET 600 East Main Street,Stockton,CA 95202-30*e Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: t9A n Page of Facility Address: R City: Inspection Dll zz G ,-, ,Cc , � � 08 FA#: PR#: Program ElemVV. 0 -Z' 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: ` TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: D ) Total Capacity: ©b gallons (per or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: �Q � Total Capacity: 15 b 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) 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 and<250 gallons) 4 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 Mall Date: (per tank or cumulative for containers by product type) — Total Capacity this Page: gallons Total Capacity for Site: 14 gallons Comments: o HHD lmpcctcr:1 / Reviewed I Date: Entered Date: By Initial: WN 1 .Ci. By Initial: a D EHD 28-01 01/16/08