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' SAN JOAQUIN COUNTY �..} ENVIRONMENTAL HEALTH DEPARTMEN- ' 600 East Main Street, Stockton,CA 95202-302-9— Telephone:(209)468-3420 Fax:(209)468-3433 Te6r www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE.PROGRAM SURVEY FORM Facility Name: 9309 1 - _ A 1<,16 C v 1l)° page of Facility Address: City: insp ionpat ' � ! b . S� - fit.✓ C./�S' �"!.�' _�G �" S?�S� �zl n� FA#: PR#: Program Element: L o g 2 �� a. -2, 8D r Tank/Container Inforithation Complete for all sites with cumulative aboveground storage of petroleum Z 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 Q50 gallons) 1 Product Type: �]O j D R -o, Total Capacity: 0 0 gallons. (per tank or cumulative for containers by product type) Install Date: Ik Tank(2820) ❑ Containers (2821) *of Containers: TAM (>250 gallons) .(>55 gallons and<250 gallons) 2 Product Type: T 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 X250 gallons) 3 Product Type: Total Capacity: gallons i (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) W.Containcrs: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 t 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) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 7 b a gallon# Total Capacity for Site: ?O gallons Comments: l --VS EHD Inspector: Reviewed Date: Entered - Date l By Initial: p�;'y. By Initial: i EHD 28-01 01/16/08 4'