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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME, 40 600 East Main Street,Stockton,CA 95202-3029 Telephone.(209)468-3420 Fax.(209)468-3433 Weh:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: � /r / d v UDS Page l Of Facility Address: City: ect te: FA#: Q p c T S , .p b l P10- Program Element: Z/Z D sys' 7 3 Tank/Container Information Comple for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55�Ls I Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Contai or§3 2821) #of Containers: TA#: (>250 gallons) (>55 Ballo and<250 lions) Product Type: Total Capacity: ... "' ga ons Install Date: ��"ftp t 'VW ) (per tank or cumulative for contain byproduct e) ❑ Tank (2820) ,Containers (2821) #of Containers: TA#: f S�D6 3 (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 0i Total Capacity: SIL gallonsSA (per tank or cumulative for containers by product type) Install Date: pi f65TNa�icl.rA.u(nG SI.!�D j2- Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: I ' [..Lr gallons I (per tank or cumulative for containers byproduct type) stall Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: q, Q, � (>250 gallons) (>55 gallons and<250 gallons) 4 Total Capacity: gallons ' Product Type: QS P.L —1PAAAO p vY,u gPxo rn hs/ ;�'� �j � (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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page 5 gallons Total Capacity for Site: gallons Comments: //N S R-41-4 J c 1-1-76 y ,0/J Lri T /C Ps L / 3 20 6519 LLo 4-S U EHD Inspector: Reviewed Date Entered Date: By Initial: By Initiate EHD 28-01 01/16/08