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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN -600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: _ •9 /f- r.�y,� G,1A4 s Page_,,z—of Facility Address: City: In ect'on e: 3 / o S S ��i�� ' ��i �oiQ T FA#: PR#: Program Element: U0 3 dp)?D S�2 7 Z�- �"l Z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 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#: f6'1&&>f (p (>250 gallons) (>55 gallons and<250 gallons) , 1 Product Type: r�,GZits�L—�°v�40 �A lid/ Total Capacity: � 6 �U O gallons Install Date- (per (per tank or cumulative fo l�onttainers by product type) nEk (2820) Containers (2821) #of Containers: TA#: 05-1 D 1 (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: / S b 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) 3 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) 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: /O /-1-0 gallons Total Capacity for Site: /p/J d gallons Comments: EHD Inspector: Reviewed D te: Entered Date: By Initial: I �� or I By Initial: �1 O EHD 28-01 01/16/08