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.5 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sygov.orglehd' F; ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: L Page. I of C I 7-Y 0,F r C A r t . Tri �T' o '.City: lnspcc'on Dat Facility Address: i .� 2 G Z6 S_' PR#: Program Elem nt- 19oq ,. Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Com Tete one box for each tank or each cumulative container product type. G Tank:'(2820) ❑ Containers (2821) #of Containers: �� TA#: (>250 gallons) (>55 gallons and<250 gallons) n ) 1 Product Type: - Total Capacity: , .� O O O gallons Install Date: (per tank or cumulative for containers by product type) f ❑ Tank (2W) ❑ Containers (282 1) #of Containers: TAM (>250 gallons) (>55 gallons and X2.50 gallons) 2 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) µ l 0 Tank 1:(2820) ❑ Containers (2821) - #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons . (per tank or cumulative for containers by product type) Install Date- ❑ Tank:(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and Q.50 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 c250 gallons) 5 Product Type: Total Capacity: gallons :(per tank or cumulative for,containers by product type) install Date: Total Capacity this Page: / p O D gallons Total Capacity for Site: /0,90, gallons Comments: k x►C_j< �Off 844 f t f i EHD Inspector: /a r L� Reviewed Date: Entered Date: By Initial: k)A (iBy Initial: ih r EHD2"1 - ` 01/16/08