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SAN JOAQUIN COUNTY -'NVIRONMENTAL HEALTH DEPARTMEN- 600 East Main Street, Stockton,CA 95202-3G- Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name- "'r 7-'� ame•j 'r7-'�A D / t' jvq0/r✓6' /lv G PageOf y Facility Address: City: Inspection D te: FA#: R _ Program Eleme Tank/Container 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 type. ank (2820) ❑ Containers (2821) #of Containers: ;A#: /7 (>250 gallons) (>55 gallons and 450 gallons) 1 Product Typ : J Total Capacity: 0 0 d gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: 2 S©TA#. LLorl (>250 gallons) (>55 gallons and 450 gallons) / 2 Product Type: le 62 Total Capacity: !. 0 gallons (per tank or cumulative for co tamers by product type) Install Date: wank(2820) ❑ Containers (2821) #of Containers: TAM /9t,6-1 71 (>250 gallons) (>55 gallons and 450 gallons) / 3 Product Type: Total Capacity: Z d O O d gallons (per tank or cumulative for containers by product type) Install Date: &KTank (2820) ❑ Containers (2821) #of Containers: TA#: Qom) 7,2Ze I (>250 gallons) (>55 gallons and 450 gallons) 4 Product Type: / Total Capacity: '2,o O 0 6 gallons ` (per tank or cumulative for containers by product type) Install Date: Lkl1'ank (2820) ❑ Containers (2821) #of Containers: TA#: P 617,2 (>250 gallons) (>55 gallons and 450 gallons) I 5 Product Type: V Total Capacity: '--y 0 O gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ,� rX gallons Total Capacity for Site: gallons Comments: 7i EHD Inspector: Reviewed Date: � Entered Date. By Initial: By Initial: R EHD 28-01 01/16/08