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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street, Stockton,CA 95202-3uz 9 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: T5 , Page I of Facility Address: D ^ A✓ P l�pe tZ.`L t Q FA#: ^ PR#: 7 n 1 P o2ramElem7 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Co Tete one box for each tank or each cumulative container product type. ❑ Tank (2820) dContainers (2821) #of Containers: Lf TA#: [p4 CIA (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: b6*(i Total Capacity: 2 2 p gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Ci"Containers (2821) #of Containers: y TA#: IL (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 6:7/�'fpf!% 71-1-2 Total Capacity: 3 C7 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and<250 gallons) Product Type: ��C/G D/ Total Capacity: Sq-0 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: Ivo7'dJe-101 t-"' Total Capacity: 3 y d 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: � dy gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: 0 k4d-- 6Qz-1 I.t/7t/v'/L9AZZE D EHD Inspector: Reviewed Date: Entered Date: ef y By Initial: V-11 <.'L1?-J1q By Initial: D EHD 28-01 01/16/08