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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street, Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: p / PD l N T Page / of Facility Address: /�y� C 2 0 0 �GANC6 C �- In/o/d/�' FA#: PR#: b /��V 000 cooProgram Elemen[: CJ 4 3 'Y Tank/Container Information Comple for all sites with cumulative aboveground storage of petroleum 21320 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#: (>250 gallons) (>55 gallons and<250 gallons) I Product Type: Y r Total Capacity: gallons -Zr r (per tyk or cumulative to con iners by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type:� n Total Capacity: 10 O ® gallons 1 S "- (per tank or emulative for containers by product type) Install Date: ❑ Tank(2820) N Containers(282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: _ i„,o 4 ,, is/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ,R Containers (2821) #of Containers: / TA#: (>250 gallons) (>55 gallons and<250 gallons) �. 4 Product Type: u%c.Q 0"/ r Total Capacity: SS gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>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: // 000gallons Total Capacity for Site: l) gallons Comments: EHD fns tor: / Reviewed Date: Entered pate; By Initial: WO �,�I l-d� By Initial: EHD 28-01 01/16/08