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SAN JOAQUIN COUNTY �sNVIRONMENTAL HEALTH DEPARTMENT". 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name. L GAL 1 N TfiQ r" l) p p L S-E9 /c1': Page of Facility Address: ,� City: Inapectio Date. 1 t—d pN11 S 4vn ! O y ST / S2o r4 2r* 0ff {� FA A: 1 Q / PRA©U O�.Z ( Progra 0 t /�v f V_ TanIdContainer Information Y Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: ' p Total Capacity: PJ d gallons Install Date: / *� (� 0" Cts (per tank or cumulative for con niers by product type) - ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) / 2 Product Type: Total Capacity: 175 gallons Install Date: (per tank or cumulative for containers by product type) El Tank (2820) B Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) J C TC- �' 3 Total Capacity: ZSgallons �A Product Type: (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: gallons Total Capacity for Site: gallons Comments: L, 13 2 o q EHD Inspector: ^ Reviewed Date: Entered Date: �f By Initial: V/1J 4 .10'A By Initial Oc D EHD2"l 01/16/08