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SAN JOAQUIN COUNTY ,_ ` IRONMENTAL HEALTH DEPARTMENT 300 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: mAzPA /A c) S -roc•KTo N Page--L of Facility Add ressOAUTd CE NTE clty` t ^TK Inap n q O.7 FA#: I`r PR PEA G J\ Progra '`Erllee_meent: o - 3 Dtsag '�DS �g 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 Ly- ank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 1 / Lic b Product Type: LL x S 2�- az Total Capacity: `�" gallons (per tank or cumulative for contamers by product type) Install Date: ❑ Tank(2820) TAt"ontainers(2821) #of Containers: Z TA#: (>250 gallons) (>55 gallons and<250 gallons) � 2 �� Product Type: /� T f . "" Total Capacity: �—gallons (per tank or cumulative for conta /iners by product type) Install Date: C2 ❑ Tank (2820) 'Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: &r Total Capacity: 22P gallons Install Date: (per tank or cumulative for containers by product type) ElTank(2820) ItoContainers (2821) #of Contain #: (>250 gallons) (>55 gallons and<250 gallons) 4 2�D Product Typ . v Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: _- Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) �) Total Capacity this Page: gallons Total Capacity for Site: �/ !/ gallons Comments: ad a ti DID Inspector: Reviewed Date: Entered Date: By lnitiaL vq)-1Q,ye6A� By Initial: EHD 28-01 U 01/16/08