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SAN JOAQUIN COUNTY V40ENVIRONMENTAL HEALTH DEPAR tMEN I 600 East Main Street, Stockton,CA 95202=302 Telephone:(209)468-3420 Fax.(209)468=3433 Web:www.sjgov.orglehd UND PETROLEUM M ABOVEGROUND STORAGE PROGRAM SURVEY FOR .. Facility Name: Page z Of+ fj C1. ✓ Facility Address: City: a inspectionPate:Voy - r FA#: PR#: Program Elent: 0,-Ae,e 'G9 [7J61 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. Com Tete one box for each tank or each cumulative container product type. Ek"Tank(2820) ❑ Containers (2821) #of Containers: .TA#: (>250 gallons) (>55 gallons and 4.50 gallons) 1 Product Type: A 4 Total Capacity: f a gallons install Date: ' (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: Z TA#: (>250 gallons) (>55 gallons and 450 gallons) 2 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 4.50 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 450 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Dale" ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) . 5 Product Type:' Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date' Total Capacity this Page: 3 gallons Total Capacity for Site: 3 gallons Comments: G ofij< .- /Q0 1/s EHD Inspector: Reviewed Date: Entered. Date: By Initial: .p`6 By Initial: } EHD 2"1 01/16/08