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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMI s, 600 East Main Street,Stockton,CA 95202 9 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/elid ABOVEGROUND PETROLEUM.STORAGE PROGRAM SURVEY FORM Facility Name: s Z /✓ " Page—/—of Facility Address: i' (� /� /�Al, J � � T City: "ZL?7 1//�. �� Ins:�7r Y [�!/ Z (� Program Element: Tank/Container Information ,' Complete for all sites with cumulative aboveground storage of petroleum ?1320 gallons in tanks and containers over 55 gallons. 1' Complete one box for each tank or each cumulative container product e., Tank(2820) ❑ Containers (2821)" #of Containers: 'r A#: (>250 gallons) (>55 gallons and<250 gallons), 1 : Product Type: ,p Total Capacity: 15) _ gallons (per tank or cumulative or containers by product type) Install Date: ❑. Tank(2820) ❑ Containers2821 ( ) #of Containers: TA#: (>250 gallons) ' (>55 gallons and<250 gallons). 2 ,. Product Type: Total Capacity: gallons (per tank or cumulative far containers by product type} Install Date: - x ❑ Tank(2820) ❑ Containers (282 1) . : #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 ;; Product Type:. Total Capacity: gallons (per tank or cumulative for containers b Install Date: (p byproduct I ❑ Tank (2820) ❑ Containers (2821) #of.Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 q 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) 5 "Product Type'. Total Capacity: gallons Install Date: (per tank or cumulative for.containers by product type) i Total Capacity this Page: gallons Total Capacity for Site: gallons I Comments: 2 ltg2onzd 4� �✓ i l EHD Inspector: Reviewed Date: _/ Entered ''Date: C d3 By Initial: Y r' By Initial: `1 EHD 28-01 �. 01/16/08 I1