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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEII., ,, X600 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 6Z,G Page S ST % �ll� /�l/=NF Ccs �— of Facility A rens: tCity: Inspectio ate: G �� ,s,F,�r �—T o Q g FA I PR#: Program[Element: 1 05',2'74? Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Co Tete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) p 1 Product Type: (it/,Q.S�e Ol Total Capacity: 5 �4' 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) 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<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 5 gallons Total Capacity for Site: gallons Comments: EHD Inspector. r� Reviewed Date: Entered Date: ( By Initial: By Initial: 12 1 EHD 28-01 01/16/08