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SAN JOAQUIN COUNTY :NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r D C Page of Facility Address: City: Inspecti n D �� FA#: PR#: Program Element: ? z95,2'F& Z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. Com to one box for each tank or each cumulative container product type. ❑ Tank(2820) Containers (2821) #of Containers: _� TA#: /�`�� / t39'3 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 4VC A'S D/L A'Qj'/T(/r- Total Capacity: 4 gallons (per 1115or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6-117, (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: �T p�. d/ �, Total Capacity: O gallons Install Date: (per7k or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TA#: 1195) 71371 (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type:�Jl�J 0 7-U/2' 0/ � Total Capacity: 7 b 4"6 gallons Install Date: (per tank or cumulative for containers by product type) PV/ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) / 4 Product Type: /11 D TO/rZ. O/CJ Total Capacity: ! 9 Y-6 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9,�� ? (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: �j � 7-0 ti D Total Capacity: 7 9 9'0 gallons (per tank or cumulative for containers by product type) Install Date: n Total Capacity this Page: 3 J gallons Total Capacity for o— /J U" gallons Comments: 77 EHD Inspector: Reviewed Date: , I Entered Date: . , By Initial: ��,2)u`� By Initial: /0 EHD 28-01 01/16/08