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SAN JOAQUIN COUNTY - �%, �ENVIRONMENTALHEALTH DEPARTMEN%� 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: 5 U ! til/ (/ — AnA?OS Page of Facility Address: 'r City: ^' z /Inspection at 1 oy FA#: PR#: t Program Element: 3 rf'8 e5a,7o 4 r -Z s a 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 type. Tank(2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: e Total Capacity: 300 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #of Containers: 'I A#: (>250 gallons) (>55 gallons and 450 gallons) 2 Product Type: � Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 Pitons) (>55 gallons and 450 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 450 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 450 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 3 D v gallons Total Capacity for Site: 3&0 gallons Comments: EHD Inspector. Reviewed Date: Enter Date: By Initial: UAJ 0- to_ By In EHD 28-01 01/16/08