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SAN JOAQUIN COUNTY ' ENVIRONMENTAL HEALTH DEPARTMEN' "00 East Main Street,Stockton,CA 95202-30� Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: , O I I Page�_of Faculty Address: /� City: Inspect! �Datq: G 2 Z A L/16 GRNIE2 G//L 7 I` FA#: PR#: Program Wemat: 2.OZ 1 0 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Com a one box for each tank or each cumulative container product type. ❑ Tank(2820) Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 61 L. Total Capacity: P d gallons Install Date: (per tank or cumulative for co�ont��ainers by product type) ❑ Tank(2820) OR Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) c 2 Product Type: Total Capacity: /in gallons Install Date: (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: Z Z� gallons Install Date: (per tank or cumulative for containers by product type) / -- ❑ Tank(2820) Cyt Containers (2821) #of Containers: / TA#: (>250 gallons) (>55 gallons and<50 gallons) 4 Product Type: O/ L Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑(Mainers (2821) #of Containers: / TAIL: (>250 gallons) "' nd<250 gallons) r 5 r) s Product Type: Total Capacity: _ ;allons (per tank or cumulative for i __�p..w;t type) Install Date: Total Capacity this Page: gallons I Total Capacity for c L v Z gallons Comments: O 1Z D A/-/q c-nvl--- LHD Inspmlor: Reviewed Date: Entered Date: By Initial V,A) 1 .4.0% By Initial: g ' EHD 28-01 01/16/08