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SAN JOAQUIN COUNTY 'y,WZNVIRONMENTAL HEALTH DEPARTMEN'" 600 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: Page of C o i✓5%n1 V cT r✓ G Facility Ad cess: City: Inspectio Date: S T ro c S'2d,� y zq Ivy FA N: � 6 PR go ,3 yD� Progr�El�ent:0 Tank/Container Information /J77�� Complete or 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 a rve container ro Tank(2820) ❑ Containers (28 #of Containers: T #: (>250 gallons) (>55 gallons and<25 uons) 1 Product Type: Total Capacity: 8 0 d Ions Install Date: (per tank or cumulative for containers by product typ8�-_._ _ ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 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) 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 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: 1000 gallons Total Capacity for Site: / gallons Comments: ,Fqz - Za r s ,VZ- zo nJ EHD Inspector: Reviewed Date: Entered to By Initial: By Initial: 1 EHD 28-01 01/16/08