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V SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT 00 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: r G Page I 1\111 � �LO13&,4k 19IN-A roW sTR of t- Facility Address: City: Inspectio Dat 61 s mag- FA#: PR#: Programiement:, 5'03 e ��g 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 t3Te. Tank (2820) ❑ Containers (2821) #;o f Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: S Total Capacity: .-0 a gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: iTA#: (>250 gallons) (>55 gallons and<250 gallons) 2 1 Product Type: �✓ Total Capacity: Z 0 d gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Ditontainers (2821) #of Containers: S TA#: Q250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: Z 7.S gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM (>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: gallons Foal Capacity for Site: r gallons Comments: 2,0 01V EHD In to Reviewed Date: Entered Date: By Initial: {}�J.�j-�}� By Initial: EHD 28-01 01/16/08