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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN `ro00 East Main Street,Stockton,CA 95202-30SO' Telephone.(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Ne: , of T A- T ' p D 130057'B2 ITATCAf Page Facility Address: City: ,/ >p inspection Date: 5 NI rA /V/ r* F/{ (/Z e FA#: PR#: Program Element: D ZS `/v 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 gYfank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) 1 Product Type: PA"-) Total Capacity: S� Oa gallons Install Date: (per tank or cumulative for containers by product type) - - ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) 2 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 Q50 gallons) 3 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 Q50 galkms) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 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: SvD gallons Comments: G✓ S 9 f � / C FEH Insprctor Reviewed Date: Entered Da tt By Initial: By Initial: eon EHD 28-01 0 /I6'08