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SAN JOAQUIN COUNTY ?NVIRONMENTAL HEALTH DEPAF :NT 600 East Main Street, Stockton,CA 95�_v/_-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: ' / `J�(/ � ' w r g J{✓( Pae of Facility Address: City: Inspect.. Date• FA#: PR#: Progvdm Ele ent: L9 512 / Z9 2,83v 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#: �,�j"��7 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: � U 0 d gallons (per tank or cumulative for containers by product type) Install Date: ER"Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: A (/tly--Iq.r Total Capacity: 5 0 0 9gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TAM X07 Li (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: 9//',S45 6, Total Capacity: 10 0 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 516P (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: D10 U G 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: EHD Inspector: Reviewed Date: pg Entered Date: By Initial: `•'Zb� By Initial: `7 EHD 28-01 01/16/08