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SAN JOAQUIN COUNTY %.J ENVIRONMENTAL HEALTH DEPARTME�*W f 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r r ly,� rW bV P VS # Page of Facility Address: p Q Cit 4t 8 6 /0'r 1442 FA#: PR#: _ Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum L>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: TAM (>250 gallons) (>55 gallons and<250 gallons) ✓ I Product Type: �® Total Capacity: ,�Cx D gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 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 450 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<250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers 6y product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumuiativc for containers by product type) Install Date' Total Capacity this Page: ' @® gallons Total Capacity for Site: (? 1 gallons Conmients: t3 7V�e EHD Inspector: Reviewed Date: Entered Date: r� By Initial: 1�.�,,. By Initial: EHD 28-01 01/16/08