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SAN JOAQUIN COUNTY 3NVIRONMENTAL HEALTH DEPARTMEl< b00 East Main Street, Stockton,CA 95202-30�-. Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd 4,1- ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: F ya LU cEle D Page of Facility Address: City: Inspecti(yi Date: 2. V ,S ZZ D FA#: F PR#: Program Element: oo/ lfy07i 1 ), g` -V 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#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 1 0 9 V 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) 2 Product Type: Total Capacity: 10 by 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: 16 VO 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) 4 Product Type: Total Capacity: NO* 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 (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: /14' �/✓E l/N/ d�' o • �0 3 EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: 1 EI-ID 28-01 01/16/08