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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN 600 East Main Street, Stockton, CA 95202--,,29 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: SO ll� ��S% Page of t/P D' __'/_ Facility Address: // a r - Z0 // City: /11A/V T= C Inspecti Date - a s/izte: © y FA #: 000 IV- 2-�3 PR #: ]S-'7 ?-- Program Element: z'?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 (2841) #of Containers: TA#: Bh_(? ' a2 7r/ (>250 gallons) (>55 gallons and <250 gallons) p 1 Product Type: 2z,��(_ � J Total Capacity: Z nO 0 gallons or cumulative for containers by product type) Install Date: ��(petank L7 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: 2_4po b gallons Install Date: c. (per tank or cumulative for containers by product type) M" ank (2820) ❑ Containers (2821) #of Containers: TA#: 96-11Pz73 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: 3 y U gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 9?tontainers (2821) #of Containers: TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: Z Sd gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) P C ontainers (2821) #of Containers: % TA#: — 7 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: - gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 6 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: By Initial: Cj �`1 ' Entered Date: By Initial: "o/' /"d EHD 28-01 01/16/08