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SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMEN"� V 00 East Main Street,Stockton,CA 95202-302 /1 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / 10 N Cr DO d A/ GRT L L a Page of Facility Address: City: Inspecti n Date: 12-.1 '/-1 vR� s Leri1 9 -1oB FA#: /4q 7 q n ,r,s PR#: Program Element:4f v a3&0 -z- d 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 Ej(Tank(2820) ❑ Containers (2821) #of Containers: TA#: e6-17 ,57F (>250 gallons) (>55 gallons and<50 gallons) 1 Product Type: Q(//1j'T/4/1 6:As Total Capacity- 00 / ® gallons Install Date: (pa ink or cumulative for contamers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gagons) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gations) (>55 gallons and Q50 gallons) 3 Product Type: Total Capacity: gallons Install Date: (pa tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) -- 4 Product Type: Total Capacity: gallons (pa 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 (pa tank or cumulative for containers by product type) Install Date: Total Capacity this Page: d © 0 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed `,A tt1 Date: Entered Date: By Initial V V,v 8, .17`F By Initial: pL EHD 28-01 VVV VVVV��„`""'' __ll 01/16/08