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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM' 600 East Main Street, Stockton,CA 95202-- Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.eigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r O C I—arJ 0 l b� �� P'r Page ( of Facility Address: City: Inspect' n Date 2 k "T �T� 5Te (r3 e'1° FA#: PR#: Program Element: O I So s2- 6/ '2- Tank/Container 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#: j�'5/& 7 /6 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 6A 5' -l/N4,640M Q Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 51 /p 7 Cr (>250 gallons) (>55 gallons and<250 gallons) 2Product Type: Total Capacity: 1,7 DO 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: 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: 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: 7 5e O gallons FTotal Capacity for Site: 7 So 4 gallons Comments: EHD Inspector: Reviewed Date: Entered �7 Date: ' ! By Initial: UA b,)70"0 By Initial: EHD 28-01 , 01/16/08 ' 4