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SAN JOAQUIN COUNTY WIRONMENTAL HEALTH DEPARTMEM 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: T16,4 L7/eA ,9 / /�/� Page z- of Facility Address: City: InspectionDate / / Q FA#: PR#: Program Ele ent: 3 l� 6- 1 66;z a 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) Contain�s��ontainers: - TA## ' —3(>250 gallons) (>55 gallons � _ 1 �.� Product Type: /�� y �Total Capacty:. gallons —1p�t nk or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) o o�Itainers: � TA#: f9 51-7 D g y, (>250 gallons) (>55 gallons 1 2 J roduct Type: �E�T TgA"jjq l 01 Total Capaci gallons ' (pe 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: 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: 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: b gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered J - DaEL By Initial: By Initial: EHD 28-01 01/16/08