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SAN JOAQUIN COUNTY —ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton, CA 95202-3&, Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 6 A (� fJ s A/ 5- 8 D Page _L-- of Facility Add ss.. � � City: / � � Inspection at FA #: PR #: Q Progrraim Element: 7-7 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 to or ertt um Yative container product type. Tank (2820) ❑ r6nt' e 2 1) " -atairfe`rs: TA#: ,7 1 f� (>250 gallons) (>5� �a n G45 �a o —' o r — Product Type: - Total Capacity:- gallons Install Date: (per tank or.cumulative for containers by product type) El Tank (2820) --1 Cont aineh-(2821) #of Containers7-t— TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity:'gallons Install Date: (per tank or cumulative for cntainers by product type) ❑ Tank (2820) 29"Containers (2821) #of Containers: TA#: ao<3 l 3 (>250 gallons) (>55 gallons and <250 gallons) r ^,(j Product Type: Total Capacity: gallons Install Date: �NjZN–{W (per tank or cumulative for containers by product type) I ❑ Tank 2820 Containers 2821 ( ) ( ) #of Containers: TA#: � 3 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: _C(� Total Capacity: gallons Install Date: �- '_a : '�'`� (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Date: (per tank or cumulative for containers by product typeInstall Total Capacity this Page: _'2..- b"` gallons Total Capacity for Site: z-�=.� r gallons Comments: 7 EHD Inspector: Reviewed Date:Entered By Initial:�. G1• b Dat By Initial: EHD 28-01 01/16/08