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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 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:12 Page of L J Facility Address: City: Ins a ion D to 213 5es-D KA S-LJ 8141 Cl �'2 G x FA#: PR#: Program ement: -2, Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_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#: D�171 I (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: '2-1 V1 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) 19/Containers (2821) #of Containers: T : (>250 gallons) (>55 gallons and<250 gallons) / � 2 Product Type: /✓ Total Capacity: -Z-1 0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (282 1) #of Containers: TA#: e 5-1 �] 173 (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Q gallons Foul Capacity for Site: gallons Comments: EHD Inspector: zv Reviewed Date: Entered Date: v By Initial: By Initial: Lod EHD 28-01 01/16/08