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SAN JOAQUIN COUNTY �R i'AL HEALTH DEPARTMENT "NViRONMEN 600 East Main Street, Stockton,CA 95202-3029 �'- ' �•_ Telephone:(209)468-3420 Fax:{209}4b8=3433 Web:www.sjgov.or eligl• d ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY.FORM - Facility Name: R f' ✓; r Page,L of City: lnspectio 'Date . Facility Address: ...., L 1 h Jr 9 1 0, �JG S` Program Element: li T�D TanklContainer Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Com fete one box for each tank'or each cumulative container product e. Tank(2820) ❑ Containers (2821)- #o.f Containers: TA#: and<250 gallons) (>250 gallons) (5-55-gallons _ ) Product Type: Total Capacity: O n d gallons. Install Date: . (per tank or cumulative for containers by product type) 1 . ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 2 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) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ` ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 050 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) E ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#:. (>250 gallons) (>55 gallons and<250 gallons) s. Product Type: Total Capacity: gallons (per tank or cumulative for,containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: ZC� � p { EHD Inspector: Reviewed ' Date: Entered Date By Initial: t�,`,�,g.p� By Initial: g a EHD 2MI r 01/16/08