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�.- SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT "'%160 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: y�l / (/�/t /� , ,",y DA� Page Z— of Facility Address: City: Inspection Date: FA#: PR#: Program Element: 7D� g Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Com tete one box for each tank or each cumulative container product type. ❑ Tank (2820) Cf ontainers (2821) #of Containers: TA#: D,5 f (>250 gallons) (>55 gallons and<250 gallons) i / 1Product Type: GtiRri`' j6 �vF Total Capacity: .f s gallons (per tank or cumulative for containers by product type) Install Date: O Tank(2820) Containers (2821) #of Containers: TAM B5 g _ (>250 gallons) (>55 gallons and<250 gallons) ,S 2 Product Type: Total Capacity: �( gallons ti (ptank or cumulative for containers b PY�roduct type) Install Date: L7-Tank(2820) ❑ Containers (2821) #of Containers: TAM [2,sj4zWf'7 (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: /9_S` 8 7 Total Capacity: /d&I G4 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: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>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: gallons Total Capacity for Site: J� 3 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: ee Q EHD 28-01 v 01/16/08