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SAN JOAQUIN COUNTY E0NVIRONMENTAL HEALTH DEPARTMENT 0 East Main Street, Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 11v G Page I of Facility Address: City: Inspection D te: o - , b/;c 6 a FA#: PR#: Program Element: aoo 6136 14!��433 �g 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. Wf Tank(2820) ❑ Containers (2821) #of Containers: TA#: p (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: J Total Capacity: Qd/ (' gallons (per tank or cumulativ for containers by product type) Install Date: GYTank(2820) ❑ Containers (2821) #of Containers: TA#: jQ �/ `7O 7 `( (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: C>1 (, Total Capacity: 27 S 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: f% 0/ Total Capacity: Jr 0 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) 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 Pio S Z S gallons Total Capacity for Sit G�Z S! gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: U� g.pb By Initial: g EHD 28-01 01/16/08