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SAN JOAQUIN COUNTY ,ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-302 Telephone.(209)468-3420 Fax:(209)468-3433 Web.www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY/FORM I Facility Name: Page l of EA5-( A �/l u h Facility Address: City: Impe ion Dat 19 N �4 FA#: PR#: Program Element: D�aSas 2 93 1 Tank/Container Information 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 type. Tank(2820) ❑ Containers (2821) #of Containers: TA#: �Q5/ 7/ Z (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: (?q b(4l' ()NI eAfA onP��Z., Total Capacity: I, OJy gallons (per tank or cumulative for c ntainers by product type) Install Date: �r N-Tank(2820) El Containers (2821) #of Containers: TA#: L-251] 19ttg 2 ( 250 gallonProduct Type: t"t' s) (>55 gallons and<250 gallons) b S Q SC L 0 Z Total Capacity: _ I ODD gallons Install Date: (per tank or cumulative for Containers by product type) Tank(2820) ❑ Containers (282 1) #of Containers: TA#: 19h!204 (>250 gallons) (>55 gallons and<250 gallons) e 3 Product Type: r) Total Capacity: 66 gallons Install Date: Cf)4al (per tank or cumulative for containers by product type) ❑ Tank(2820) Containers (2821) #of Containers: i TA#: (>250 gallons) (>55 gallons and<50 gallons) q Product Type: QTb Sen)2, Total Capacity: S gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: ,S gallons Total Capacity for Site: 2 , gallons Comments: S cc l V 9 e . EHD tor. / Reviewed Date:y Entered Date: By Initial: �,l b.V� By Initial: EHD2MI �/ P 01/16/08