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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME _ )NOW 600 East Main Street,Stockton,CA 95202-021 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM '� /r, Page 1of _ y Facility Na G ffe� r v Facility Address: , City: V Inspectio Date: 21 ?. F• /a/ nl et/ z 6 ��ii (� 1 [n m Program Eleent: FA#: 000 PR#:S/V 3 V / �O Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Conlplete one box for each tank or each cumulative container product ❑ Tank(2820) Containers(2821) #of Containers: 3 TA#: (>250 gallons) (>55 gallons and<250 gallons) I Product Type: 4±1 Total Capacity: � gallons (per tank or cumulative for containers by prodtxt type) Install Date: ❑ Tank(2820) ❑ Containers(2821) #of Containers: 7/ TA#: 2 (>250 gallons) (>55 gallons and<250 gallons) Product Type: /&jq Tls /i .✓ �1 /-F� _ C f� Total Capacity: Un 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) 3 Product Type: Total Capacity: '/ e3gallons (m 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: r Total Capacity: / S- gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) Containers (2821) #of Containers: y TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: 0 / L Total Capacity: Z �4-8 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: Entered Date: By Initial: W4 By Initial: 1' <. EHD 28-0I 01116/08