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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN o00 East Main Street, Stockton,CA 95202-302y Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r t16'5- 7�?rrClK S�O'p Page/of Facility Address: City: Inspect n D e: 3 5 0 s w s T /Lg szt, z og FA#: _ P #: ProgramElement: 2 9 Tank/Container Information Complete all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. Co Tete one box for each tank or each cumulative container product type. Tank(2820) ontainers (282 1) #of Containers: 7A#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: !9!• L. Total Capacity: d gallons (per tank or cumulative for containers by product type) Install Date: 77 ❑ Tank(2820) Di Containers (2821) #of Containers: ,� TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Q�• �..� Total Capacity: Z75 gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and<250 gallons) Product Type: bt"19f rj O Total Capacity: �-1&0 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) 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) $ Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: d 9 gallons Comments: g-r 0L- 26,2Wlr WA /1lpi/4kj o . j3d)c SS'z`f'v S Tom- c°�0 9S zoS z � .. Dt�463 EHD Inspector: Reviewed1 Date: Entered Date: By Initial: 1 "�/� By Initial: EHD 28-01 01/16/08