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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT X600 East Main Street,Stockton,CA 95202-3029�a'�' Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page / Of / DE T D knl Facility Address: City: Impecti n Date• Z n/T � Gil S"TDGlGT r.l 7 3 d 0� FA#: PR#: Program Element; woz6 I 05-2-g0z1 -L 3 / 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: TA#: 22 42<3 Le (>250 gallons) (>55 gallons and<250 gallons) 3 a 1 Product Type: Total Capacity: _ 150 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) RIC-ontainers (2821) #of Containers: TA#: /5Tt /UFS Zo / (>250 gallons) (>55 gallons and<250 gallons) t 2 Product Type: A� Total Capacity: / 7-6 gallons (per tank or cumulative for containers by product type) Install Date: ai� _ ElTank(2820) R Containers(2821) #of Containers: 2" TAM (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: dyi [i Total Capacity: ZIP gallons Mall Date: (per tank or cumulative for containers by product type) cy - -- ❑ Tank(2820) m,Containers (2821) #of Containers: TA#: Qui (p (>250 gallons) (>55 gallons and<50 gallons) 4 _Product Type: /. _J /� dI1i Total Capacity: L �-galtons Install Date: (per tank or cumulative for wtnt6 .. s by product type/�(t�/r/, - 'J Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<50 gallons) 5 D Product Type: PYA � 17 Total Capacity: / 0 gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 2-0 gallons Total Capacity for Site: ZD gallons Comments: EHD Inspector: Reviewed Date: Entered Date: CBy Initial: ( � 9•q- By Initial EHD 28-0I / 01/16/08