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SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMEY, 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 EHD 28-01 01/16/08 i7 Facility Name. nn 11 (�v. No ill `,QA-�'j7r6'�1 Page of - Facility Address: �7 City: p a yeation Date: �/jfJ�lJ r FA #: PR #: rogram Element: 8'3 I Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. C Tank 2820 ❑ Containers 2821 ( ) ( ) #of Containers: TA#: , 11-9� I (>250 gallons) (>55 gall ns and <250 gallons) 6(MU1 J Product Type: {� Total Capacity: j gallons Install Date: (per tank or cumulative for containers by product type) El Tank (2820) [Containers (2821) #of Containers: I TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: 4'n1 61I Total Capacity: I tb gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ,�ff Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) � � Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) El Tank (2820) Containers (2821) #of Containers: n L TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: I k Total Capacity: SJ X Z gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) lkontainers (2821) #of Containers: 9__ TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Total Capacity: ` '42— Product Type: Gov ul I 1�5b i.j lb iv 7— gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: X66 gallons Total Capacity for Site: L gallons Comments: 1 " EHD Inspector. ' Reviewed By Initial: Date C b Entered D e: By Initial: l O EHD 28-01 01/16/08