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SAN JOAQUIN COUNTY ?NVIRONMENTAL HEALTH DEPARTMENT o00 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name- )q"^/ _ / ; l� � d /* v V/rJ�' l N �/ Page_�of y Facility Address: City: Inspection Dpte FA#: R Program Eleme 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. ank (2820) ❑ Containers (2821) #of Containers: TSA#: D6-1 74�- (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: L/W V ! 0 A Total Capacity: b d gallons �- (per tank or cumulative for containers by product type) Install Date: Elrl UIV VM2 Tank (2820) C #.ontainers (2821) #of Containers: 2 TA �0 L L� (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: LIWUID 45MALf Total Capacity: o gallons Install Date: tain (per tank or cumulative for co ers by product type) C"Tank (2820) ❑ Containers (2821) #of Containers: TA#: 426D 7o'z&J (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: 16 O O d gallons (per tank or cumulative for containers by product type) Install Date: E2,`Tank(2820) ❑ Containers (2821) #of Containers: TAM Qom)7 07 (>250 gallons) (>55 gallons and<250 gallons) n 4 Product Type: l/T /a S 31 Total Capacity: '2,o U a 6 gallons (per tank or cumulative for containers by product type) Install Date: El, 1'ank(2820) ❑ Containers (2821) #of Containers: TAM P;51 7a (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: -2-0 O 6 0 gallons (per tank or cumulative for containers by product type) Install Date' Total Capacity this Page: 0 gallons FTotal Capacity for Site: -3/6 roo gallons Comments: EHD Inspector: Reviewed Date: / Entered Date: C By Initial: By Initial: G� EHD 28-01 01/16/08