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i f SAN JOAQUIN COUNTY - "Ji INVIRONMENTALNEALTH DEPARTMI Iv 600 East Main Street1 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: 4 d K r� 12 [f G k I tv 67 " Page of Facility Address: „City: Inspection D te: O -060 , A2E' ), FA#: PR Program Eleme t Tank/Contaner Information Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or1:each cumulative container product type. Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type-' S`g�, p Total Capacity: 3 o t9 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and C250 gallons) r 2 Product Type: Total Capacity: / 0 y gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) go f Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 4 Product Type: Total Capacity: 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 Install Date: (per tank or cumulative for containers by product type) Total Capacity Phis Page: gallons Tota!Capacity for Site: gallons Comments: Y, L 3 za 6-4/10w5 END Inspector: Reviewed Date: Entered Date: " > By initial; �'_r�_i)� By Initial: END 28-01 01/16/08 { s ;F