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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEP 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: l' 2 Dl� w ou� �, ( +� t�/✓� Page L of Facility Address: City. Inspect' n Date: ?Ob 3 v P, �?s L�G FA#: �� / PR#O� � � � Prog m Eleni t12 g : Tank/Container Information Complete for 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) El Containers (2821) #of Containers: TA#: 10 l ' I/ (>250 gallons) (>55 gallons and<250 gallons) 1 I Product Type: e Total Capacity: D LOC gallons Install Date: (per tank or cumulative for co tainers by product type) x Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55allons and<250 gallons) 2 -7�f�f, �- Product Type: j 2Se L, / f Total Capacity: gallons (per tank or cumulative for con iners by product type) Install Date: / CP x] Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 0 (>250 gallons) (>55 gallons and<250 gallons) 3 ke- ✓3 Total 6pacity: gallons f (per tank or cumulative for'containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and<250 gallons) 4 4 2, Lo y 0 Product Type: otal Capacity: allons �— (per tank or cumulative for containers by product type) Install Date: X.Tank (2820) El Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 3 42, 4a q0 Product Type: Total Capacity: gallons Install Date: /� (p (per tank or cumulative for cont niers by product type) / Total Capacity this Page: gallons Total Capacity for Site: 6 (� gallons Comments: SPCIIC P S-)11) /"E I EHD ecto �Reved � Date: � � Entered Date: al: - By Initial: ! B EHD 28-0 I 01/16/08