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SAN JOAQUIN COUNTY CK yWENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Jnt /� 9) I n � G O Ci /I/c% Page of Facility Address: City: laspectl Dyt O� S oN,aU 7 T� I E FA#: 3 PR#: ProgramEleme •�S e age 7Z F- / Tank/Container Information Comp-tete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Com tete one box for each tank or each cumulative container product ❑ Tank(2820) Containers (2821) #of Containers: y TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: gallons (pa tank or cumulative for containers by product type) Install Date: El Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 4't//.1 r T� /17i Total Capacity: 3 ro 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: S .� 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: (pa tank or cumulative for containers by product type) Total Capacity this Page: S gallons Total Capacity for Site: �� t gallons Comments: EHD Inspector: Date: Entered / Date: (:r—_ Vim' By Initial: \IVTj w-1 By Initial: l I roh EHD 28-01 01/I6/08