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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEX ' 440X600 East Main Street,Stockton,CA 95202-30 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name-z,,qr,& Page, !7 S 7-d�,,� Page !of n L_ W GS / City: Inspection Da Facility Address- �j FA#: PR#: Progra Ele ent: . ao _ d 5a85 y 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 e. Tank(2820) ❑ Containers (2821) ##of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons)' J'") 1 Product Type: f� Total Capacity: n gallons (per tank or cumulative for containers by product type) Install Date: ElTank(2820) ElContainers(2821) ##of Containers: TA#: ( 250 gallons): (>55 gallons and X250 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 Q50 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: i Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: t • ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) 05 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:' gallons Total Capacity for Site: s 406 gallons Comments: 1,6 a i EHD Inspector: Reviewed ' ,�f Date: Entered r Date By Initial: VV" QIYa�O By-Initial: t - 1 EHD2"I 01/16/08 S