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SAN JOAQUIN COUNTY I$Ec ` NVIRONMENTAL HEALTH DEPARTMEN 00 East Main Street, Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: o G KT 0 A 6J,gAl � Page of Facility Address: City: Inspec i 2 V ` / � V a /!�"i9I/y D2 Tl� FA#: PR#: Program Element: ISD aD © z.P.3 Tank/Container Information Complete or 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. Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: It, Total Capacity: ��"y gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: D5171 l a (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: l�/�/Z,� G/ � Total Capacity: S C gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: e/�� (>250 gallons) (>55 gallons and<250 gallons) �— 3 Product Type: Total Capacity: G!� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) [A Containers (282 1) #of Containers: _� TA#: 6-17 1 (>250 gallons) (>55 gallons and<250 gallons) r 4 Product Type: �� Total Capacity: 5 gallons (per tank or cumulative for containers y product type) Install Date: El Tank (2820) Containers (282 1) #of Containers: TA#: /�6 (>250 gallons) (>55 gallons and<250 gallons) Type: 5 Product T e: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page• gallons TTotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date• j By Initial: V"t By Initial EHD 28-01 01/16/08