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SAN JOAQUIN COUNTY yoNVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: I / C A .e6J it,E,2 Vl c e ��STY-113 B Page__L of Facility Address: City: Iuspec"on Dale: ®v Erhq pPAE VO TRAM 3e 1p8 FA#: PR#: Program Element: j 054951e 2 9 3 —A-- Tank/Container Tank/Container Information 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 Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: T 0O '9�CE 4i Total Capacity: /s O �© gallons !:r_ :tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: D l 7 3a (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: G "A/C D(65,6:i�, Total Capacity: /✓&ito 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) 3 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) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 3('3 ©(?('J gallons Total Capacity for Site: _ Q t3 gallons Comments: EHD Inspector Reviewed Date: Entered Date / (_ r g}� By Initial: VA to.V By Initial EHD 28-01 01/16/08