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SAN JOAQUIN COUNTY __;NVIRONMENTAL HEALTH DEPARTMEI` 600 East Main Street, Stockton, CA 95202-302y Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: %/✓S�''/� t/G/C �'A � f Page / of� Facility Address: City: 6k? Inspectio Date: 6 F FA #: PR #: Program Ele ent: 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#: OS �o©I 1 (>250 gallons) (>55 gallons and Q50 gallons) Product Type: /,r/ /� s`T/ O/ � Total Capacity: ,S OD gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: l b 1 7 �13 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: /'Lj o 7-0 /Z- p j L./ Total Capacity: 0 D Dy gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: f TA#: 051 Ort C) 3 (>250 gallons) (>55 gallons and <250 gallons) E Product Type: Total Capacity: _�_5 gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0 (e, �� t 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: D� Total Capacity: 0,0 d gallons Install Date: (per tank or cumulative or containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: T)A#: 0":;-( 6tol i-- 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: L/ / Total Capacity: /0004 gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 5 gallons FTotal Capacity for Site: Z/ STT gallons Co EHD Inspector: Reviewed Date: By Initial: k�jo �, �� , Entered Date - By Initial: 2 EHD 28-01 01/16/08