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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMED�, X600 East Main Street,Stockton,CA 95202-302s Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Named _ Y /T S �_ 11f / 1-&Q Page of Facility Address: City: lty [nsp rl - � Ayf R E A _rG/ OIV FA#: PR#: Program o e� /2-37/ 0V . 3 - PUgr Tank/Container Information Comple 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 Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) ^ ry l Product Type: 666 !Y [T Total Capacity: �gallons (per took or cumulative for containers by product type) Install Date: ank(2820) ❑ Containers (2821) #of Containers: YAM 2 (>250 gallons) (>55 gallons and<250 gallons) � �_ X/✓A Product Type: Total Capacity: '7010 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) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: _ ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cur n lative for containers by product type) Install Date: _ ❑ Tank(2820) ❑ Containers (282 1) #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: Pd gallons Comments: EHD Inspector. �p �- Reviewed - ,1 Date: Entered Date: L� By Initial: VNt1 •)-o-01 By Initial: EHD 28-01 01/16/08