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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN- "X600 East Main Street,Stockton,CA 95202-3029" Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: A L 104 Al, Z-,4111 Page l of Fanz3 Address:^ City: '�CA L01 Inspec7 Datg o? FA#: ✓ PR W Program Element: aS7 zi? q0 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 type. Tank(2820) ❑ Containers (2821) #of Containers: TAM(>250 gallons) (>55 gallons and<250 gallons) 4 n 1 Product Type: Total Capacity: C gallons Install Date: (per tank or cumulative for con finers by product type) _ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and Q50 gallons) n 2 Product Type: n Vi Total Capacity: �j 5 d gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: T #: (>250 gallons) (>55 gallons and<250 gallons) " 3 Product Type: Total Capacity: Z S b gallons Install Date: \ (pa tank or cumulative for containers by product type) VatTank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) - -- 4 Product Type: /N,q$}` r 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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: _- - Total Capacity this Page/ 7j gallons Total Capacity for Site: Z S0 gallons Comments: L ! 3 Zb 6-A860- EHD Inspector: r n Reviewed 1 Date: �,p� Entered I ,n Date: (rGf1i. By Initial: %4j �,�j'" I By Initial: e a g EHD 28-01 V" ((/�1�� t 01/16/08