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SAN JOAQUIN COUNTY f" �ENVIRONMENTALHEALTH DEPARTMENTO 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 Name: Page of Facility Address: City: I'377 spec'on Dat [-�0w[ 4� - , L4 .1 �p 3 i� c)8 FA#: PR#: OS t 5— ? Program Element: Cf�j Program 0 11'_1 - Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: rj -f�(j jure (>250 gallons) (>55 gallons and<250 gallons) 1 PIoduct Type: T) l eSc-,L. Total Capacity: 10 00 gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: jhy,5:i67U,a (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 1 � �✓ �'' Total Capacity: DC7 V 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: Z 56 gallons (per tank or cumulative for containers by product type) Install Date: b'1 ❑ Tank (2820) ?,Containers (282 1) f Containers. TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: L U_Lq I'i C_A l e->rL Total Capacity: 1,018 � gallons " (per tank or cumulative for containers by product type) Install Date: If d ❑ Tank(2820) )I Containers (2821) #of Containers: Z TA#: (>250 gallons) (>55 gallons and<150 gallons) 5 ,L U Product Type: [J(J�r � C.��- 1r� Total Capacity: Z gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ! d U gallons TTOtal Capacity for Site: 3 ��(, gallons Comments: C, Q2 t/ J „1 EHD Inspector. Reviewed Date: Entered Date- 31 By Initial: a� By Initial: y EHD 28-01 v t� 01/16/08