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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN" '40%00 East Main Street,Stockton,CA 95202-302)yo, Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r'I b` ! C n1 fp cf /4( Page of Facility Address: C' Inspectionte d A 6� C)NAv? T rl'bci ld q1240Y FA#: PR#: Program Element: 1 X367 - 2 Wo Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Com to one box for each tank or each cumulative container product ❑ Tank(2820) ontainers (2821) #of Containers: TA#: -i (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: �� Total Capacity: Z 5 6 gallons Install Date: (per tank or emulative for containers by product type) ❑ Tank(2820) M15ontainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: j-jyx i 4i Total Capacity: _ S-5 gallons stall Date: E� (per tank or cumulative for containers by product type) ) ❑ Tank(2820) Containers (2821) #of Containers: / TAM (>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) W-t ontainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) .y. /-� 4 Product Type: / / Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) PI Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) of 5 Product Type: Total Capacity: t oO gallons Install Date: (per tank or cumulative for containers by product type) -- - Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: C13 � &,A/160S EHD Inspector: Reviewed Date: Entered Date:/y By Initial: �� a.�,.0� By Initial: '7 EHD 28-0t 01/16/08