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SAN JOAQUIN COUNTY :NVIRONMENTAL HEALTH DEPARTMENT 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: ,,// _ z/ TE--: l UG lc- S � L.� Page�_of Facility Address: City: Inspection ate: Nt+ v 'Yo FA#: PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Comp1gre one box for each tank or each cumulative container product type. ❑ Tank (2820) 416litainers (2821) #of Containers: Y TA#: (>250 gallons) (>55 gallons and<250 gallons) � 1 Product Type: /h�L.# Total Capacity: 11P gallons (per tank or cumulative for containers by product type) Install Date: ank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: lit// 1' ��' D/ Total Capacity: 6 ? r gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Z'Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Ca ap city: 2-Sd gallons er tank or cumulative for contain t e) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: 37 (> 50 gallons) (>55 gallons and<250 gall ` l Product Type: �1 d1�0l� D/ Total cl y: g s tank or cumulative for containers by product type) Install Date: Tank(2820) El Containers (2821) #of Containers: TA#: 1951`7 F (>25 ons) (>55 gallons and<250 gallons) Product Type: A?0'/rd le— Q (/ o a apace y: .�Gp gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 3 d 3� gallons Comments: EHD Inspector: Reviewed Date: Entered Date: i / By Initial: By Initial: EHD 28-01 "1 01/16/08