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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTM <br />%600 East Main Street, Stockton, CA 95202-302 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.orglehd <br />AROVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name: <br />Page of <br />DO P0 <br />L , <br />t S <br />—L <br />Facility Address: <br />City: <br />Inspec t O8 <br />/VC <br />S5� 9 F, <br />5'7-- �A1v7A <br />FA #. <br />PR #: <br />Prog m Elem nt: <br />YA 010 o <br />pAO �" <br />2 <br />Tank/Container Information <br />Complete for all sites with <br />cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br />Complete one box for each tank or each cumulative container product type. <br />Tank (2820) <br />❑ Containers (2821) <br />#of Containers: <br />TA#: f�61,$ /9_. <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />1 <br />Total Capacity: <br />f 2 O O d gallons <br />Install Date: <br />(p or cumulative <br />for containers by product type) <br />Tank (2820) <br />❑ Containers (2821) <br />#of Containers: <br />TAM �5 d <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />O 0,0 <br />2 <br />Total Capacity: <br />p y: <br />gallons <br />—�� ? <br />Install Date: <br />(per tank or cumulative <br />for containers by product type) <br />XTank (2820) <br />ElContainers (2821) <br />#of Containers: <br />TA#: <br />o gallons) <br />(>55 gallons and Q50 gallons) <br />Product Type: 0 <br />3 • • ti — <br />3 <br />Total Capacity: <br />_ gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) <br />❑ Containers (2821) <br />#of Containers: <br />TA#: <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />4 <br />Total Capacity: <br />gallons <br />Install Date: <br />(per tank or cumulative <br />for containers by product type) <br />❑ Tank (2820) <br />❑ Containers (2821) <br />#of Containers: <br />TA#: <br />(>250 gallons) <br />(>55 gallons and <250 gallons) <br />Product Type: <br />5 <br />Total Capacity: <br />gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: 2, <br />gallons <br />Total Capacity for Site: Z O p gallons <br />Comments: <br />EHD Inspector: // <br />Reviewed ^ <br />By [nitiaL G <br />W <br />( 6 <br />By Initial: Date: <br />EHD 28-01 <br />01/16/08 <br />