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+E�jjam��__� SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMEI _ 00 East Main Street,Stockton,CA 95202-302,9 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of FacfatyA dress: City: Inspection ate: _7_/¢ � 3s- W• .� lL T FA#: PR#: Q Program Element: O O O rZ.g? �'OQa 5/ 28fY 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) El Containers (2821) #of Containers: TAM 6JrfCP7J4 5 (>250 gallons) (>55 gallons and<50 gallons) �� 1 t Product Type: s_t3 J Total Capacity: /1, 066 gallons Install Date: (per tank a emulative for containers by product type) (Tank(2820) ❑ Containers (2821) #of Containers: TA#: 65f (>250 gallons) (>55 gallons and<50 gallons) 2 1060 Product Type: 1-1&" i Total Capacity: 4dbaqAgallons (per tank or emulative for containets by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers A#: 0 1 LP 3[o- (>250 gallons) (>55 gallons and<250 gallons) 3 � Product Type: Total Capacity: 3,0 D--0 gallons Install Date: (per tank or cumulative for containers by product type) Tank(2820) ❑ Containers (282 1) #of Containers: TA#: 125-1 LPv log_ (>250 gallons) (>55 gallons and<250 gallons) .. 4 Product Type: Total Capacity: Cep v- gallons Install Date: (per tank or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: A#: (>250 gallons) (>55 gallons and<250 gallons) S Product Type• Total Capacity: ? 00 gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: I-o 3 �f EHD Inspector: Reviewed Date: j1 Entered Date: ` By Initial: � 5,1ft^D By Initial Sj EHD 28-01 01/16/08