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SAN JOAQUIN COUNTY _ ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029"l Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: R G � Page of Facility Address: City: Inspectto Dat z6vfo P`p-z-1-) plz 7' 08 FA#: PR#. Progiak Medient- 00 11/-Ll-Z# 1 ©5a ?Af 2:2iff2) Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product Tank(2820) ❑ Containers(2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 4/1 'a f jE O /IZ57 Total Capacity: 3 by gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: ` TAM, (>250 gallons) (>55 gallons and<50 gallons) 2 Product Type: l/ Total Capacity: 2 7 d gallons stall Date: (pet tank or cumulative for containers pro ners by duct type) ❑ Tank(2820) &Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type:_ Total Capacity: / ZD 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) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ ontainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<50 gallons) 5 Product Type: Total Capacity: gallons (per tank or emulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 8 gallons Comments: w EHD Inspector: Reviewed Date: Entered Date: By Initial: C6 By Initial: EHD 2"1 01/16/08