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SAN JOAQUIN CO %(0NVIRONMENTAL HEALTH=RTMET East Main Street,Stockton,CA 95202-30 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROG'R'AM SURVEY FORM' Facility Name: /)/��/G r/ �n� Page Of 7 SU G (�G „1 'V�1 /// Inspe do Da e: Facility Address:_.7 Cts 2 6 3 pi✓ 6: v/AIJE , - F G 7 e FAN. PRH: Program Element: D o /6 8 0 5agis 2 (Fank/Container Information Complete for al ites with cumulative aboveg ound storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ❑ Tank(2820) UP ontainers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: O/ Total Capacity: / ZO gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820 ✓Q Containers (2821) #of Containers: L_ TA#: (>250 gallon )s) (>55 gallons and<250 gallons) 2 Product Type: J Total Capacity: �gallons Install Date: (per tank or cumulative for containers by product type) n ❑ Tank(2820) P Containers (2821) #of Containers: ' TAMF/h l /a �)r R/x (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: / 2y gallons Install Date: O/ (per tank or cumulative far containers by product type) El Tank(2820) O Containers (2821) #of Containers: �' TA#: (>250 gallons) (>55 gallons and<250 gallons) n T1c 4 Product Type: 1V Total Capacity: gallons Install Date: (per tank or cumulative for c ers by product type) ❑ Tank(2820) QRContainers (2821) #of Containers: TA#: IN9 �a2 (>250 gallons) (>55 gallons and<250 gallons) L v O 5 Product Type: �(,��/Q R / / Total Capacity: / rO gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: S gallons Total Capacity for Site: gallons Comments: EHD Inspector. Reviewed Date: Entered Datye: r By Initial: l� -1-%-DIC By Initial: G l 1 EHD 28-01 01/16/08