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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN' 000 East Main Street, Stockton, CA 95202-302, Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: !/A/ 1 D- T� A C / C Page ofy Facility Address: _ City: In t* n Date: FA #: PR #: Program EjpjnWt: 7 _ '24? GLS -2--s I 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. vi Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 1 Product Type: Total Capacity: gallons _ Install Date: 4, (per tank or cumulative for containers by product type) / _ -.ik (2820) ❑ Containers (2821) #of Containers: TA#: B 151 2 (>250 gallons) (>55 gallons and <250 gallons) , Product Type: Total Capacity: _ gallons Install Date: (per tank or cumulative for contamers by product type) ❑ Tank (2820) 1 _ _,atainers (282 1) #of Containers: TA#: g `� (>250 gallons) (>55 gallons and <250 gallons) _ , 3 Product Ty --- Total Capacity: _ gallons Install Date: (per tank or cumulative for conta- -rs by product type) ank (2820) -onta ni ers (2$21) #of Containers: TA#: 4 >250 gallons) k>55 gallons and <250 gallons) ✓ e Product Type: Total Capacity: 2 gallons Install Date: (per tank or cumulative�r containers by productJype) Tank (2820) ❑ Containers (2821) #of Containers: TA#:1 (>250 gallons) 5 (>55 gallons and <250 gallons) � Product Type: L2,( F_ _T r G Total Capacity: / gallons Install Date: Total Capacity th` gallons FTotal Capacity f gallons Comments: f l762� CAA, EHD Inspector Reviewed By Initial: 1 Date: nl Entered Date: By Initial:1) ) - AA �'/A EHD 01/16/08