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SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTME* 600 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: / / fit/'/ )FY T S V2T 'ON Page of Y Faciat Address: City: Inspecti FA#: PR#: Program Element: D00123Qq SS2 'T .3V 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#: p,S1 & 1'90) (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: I o CO) o gallons (per or cumulative for coAtainers by product type) Install Date: Tank(2820) ❑ Containers (2821) ##of Containers: TA#: &,,07)It )Q� (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: �� Total Capacity: 101006 gallons Install Date: (per tank or cumulative for con iners by product type) Tank(2820) ❑ Containers(2821) #of Containers: TA#: 6 Sl li W;I_ (>250 gallons) (>55 gallons and<250 gallons) 3 Iy 0 OB Product Type: Total Capacity: gallons (per tack or cumulative for c n[ainers by product type) Install Date: I/Tank (2820) ❑ Containers (2821) #of Containers: TA#: D (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: 3 10 gallons (per z cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#:p,�� (>250 gallons) (>55 gallons and<250 gallons) �— 5 Product Type: Total Capacity: Sc6 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 3 0 jf3 gallons Total Capacity for Site: 3lf gallons Comments: EHD Inspector. Reviewed e' Entered Dat C By Initial: By Initial: B EHD 28-01 01/l6/08