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SAN JOAQUIN COUNTY ?NVIRONMENTAL HEALTH DEPARTMEN- o00 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: t A (i. L) / Page --Z-- of Facility Add r ss: City: - IT T L Inspection at : FA #: 71�,-2, PR #: `3 //-b Program Element: -2- Tank/Container 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#: 1 (>250 gallons) (>55 gallons and <250 gallons) o Product Type: %�->?S�� / 0 O lbgallons Total Capacity: Install Date: (per tank or cumulative for containers by product type) ` ❑ Tank (2820) 2/containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: S 5 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) 21"Containers (282 1) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: /� //dc� (� Total Capacity: E,5 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank 2820 Containers 2821 ( ) ( ) #of Containers: -z__ TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: /''-;7 o J ��' P� 3• Total Capacity: / JO gallons Install Date: (per tank or cumulative for container; by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 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: gallons Total Capacity for Site: f gallons Comments: A� / Ulv EHD Inspector: Reviewed Date: By Initial: cj.l • 0 � Entered Dat By Initial: �� © EHD 28-01 01/16/08