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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT *'%00 East Main Street,Stockton,CA 95202-3029W Telephone:(209)468-3420 Fax:(209)468-3433 Web.www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: `n O� .�AAtt f CUUNfy 4F 5`Ary ToAQur0s , PA7. 7):OPage of_/___ Facility Address: I City: Inspec'on D e: 7o Sd E . . ..0 .. DikaA 31T sva/ / P76 FA#; �T Program Element: q 1126? JC zgo6 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 LN" "rank 2820 ❑ Containers 2821 ( ) ( ) #of Containers: ' TA#: (>250 gallons) (>55 gallons and<250 gallons) l Product Type: Total Capacity: / a O O 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) Product Type: Total Capacity: gallons (per lank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons (pa tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: 'I A#: (>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: TA#: (>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: ,a[Ions Comments: Al ,- CclAAAFT /t/ / O,*r- 7AN/< GOGAS!,q EHD Inspector: Reviewed Date: EnteredDate: By Initial: .) . V� By Initial: EHD 28-01 r. 0l/16/08