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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEI 600 East Main Street, Stockton, CA 95202-30L9 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Na F. Page / of Facility Address: V 4 0 l 46: . PAA / �- C� City: A ov?r c1A Inspectio Date: l D FA #: nnn O PR #: S Zv Program Element: 2 3 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) ❑ Containers (2821) #of Containers: TA#:'L (>250 gallons) (>55 gallons and <250 gallons) 1 /0 d a Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) kre"Tank (2820) ❑ Containers (2821) #of Containers: TA#: t2 J 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: �YA S Total Capacity: a O 6 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 <250 gallons) 4 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 <250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: Z O U O gallons Total Capacity for Site: Z 0, O v gallons Comments: dr 1 EHD Inspector: �/ �e I Reviewed By Initial: Date:(] C'-1�--° O Entered Date: By Initial �l EHD 28-01 01/16/08