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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 NA -F. a ,,� �3 511A1ST J' t!0 /►'I/=/►rT ['�t �-� G Page 4— of Facility Ad ress: City: Inspectio Date: � !� C-:7- lz�r`is FA#: PR#: . fProgram Elemenh D5�`76? Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Corpplete one box for each tank or each cumulative container product type. ❑ Tank(2820) nin - 821) #of Containers: ,4, TA#: O S (>250 gallons) (>5allons) 1 Product Type: --L Total Capacity: llons i�,5 eA— (per tank or cumulative for cype) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 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 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 X250 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: gallons Comments: I EHD Inspector: Reviewed ,J Date: Entered Date: 1 By Initial: �` 2 By Initial:jz,LG EHD 28-01 J o 01/16/08