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SAN JOAQUIN COUNTY ENvIRONMENI'AL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Factaty Name: l/ 0 L /R Page of Faculty Address. City: InspectiogDa(e: O D C 'f r FA#: PR#: Program Element: s� 1 0 7 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. EJ/Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 �_ Product Type: Lf/iq�T� '21`, � Total Capacity: �(gallons Install Date: (per tank or cumulative for containers by product type) - Tank (2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: /h o i"0�� 0/ Total Capacity: '3 -56 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: .�,5 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) 4 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<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ® gallons 'I oral Capacity for Site: dj gallons Comments. 3 Z0 G-6/ / 0 Al c EHD Inspector: /? Reviewed , - _ Date: Entered Date: C- :fes By Initial: �vI ty%-O� By Initial: g eJ EHD 2"1 V riv✓ 01/16/08