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SAN JOAQUIN COUNTY _� .ENVIRONMENTAL HEALTH DEPARTMEN' ' `1 600 East Main Street;Stockton,CA 95202-3022 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / ,f page of Facility Address: fs City: Inspe tion Da 7 D o � � l r�Np 2 a C FA#: PR#: �; p a D off, X732 ®S Z 3?� Proms aS' o Tank/Contamer Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or''each cumulative container product e. Tank 2820 ❑ Containers 2821 ( � ( ) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) - 1 Product Type-. Total Capacity: 3 d C) (per tank oumulative for containers by product type) Install Date: El' Tank 2820 ❑ Containers. 2821 1! ( ) ( ) #of Containers: TA#: . ( 250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons i; (per"or cumulative for containers by product type) Install Date: ❑ Tank 2820 ❑ Containers 2821 Tank(2820 ( ) #of Containers:. Tl (>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 (282 1) #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) #o£Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 5 Product Type:: Total Capacity: gallons Ins (per tank or cumulative fortall Date: ,containers by product type) t Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: 7o p ?. jF 32 - 13HD Inspector: Reviewed Dat . Entered Date: By Initial: 1"LL. By Initial: EHD 28-01 01/16/08