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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMI ' 600 East Main Street, Stockton,CA 95202-.,;,� Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: l/r✓/OPage _of_j— Facility Address: City: Inspecti n D te: FA#: PR#: Program E ment: 00 rd Z/ 1S S"z 3 3 r Y -2— v Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. �_ ff Complete one box for each tank or each cumulative container product e. M;, an (2820) ❑ Containers (2821) #of Containers: TA#: 1195/(0 7 D T (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: (per or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: 742 (>250 gallons) (>55 gallons and<250 gallons) ©` 2 Product Type: Total Capacity: 1�y U gallons - (per tank or cumulative for containers by product type) Install Date: ar Tank (2820) ❑ Containers (2821) #of Containers: TA#: (� (>250 gallons) (>55 gallo and<2510 gallons) 3 , C7 Product Type: I Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: © Tank (2820) Containers (2821) #of Contairker: TA#: d J 7 l (>250 gallons) (>55 gallons and<250 gallons) fvLv 4 250 Product Type: (7 4— Total Total Capacity: -� gallons Install Date: (per tank or cumulative for containers by product type) M Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 (>250 gallons) (>55 gallons and<250 gallons) 5 a4x Product Type: /f Y 17/co Total Capacity: gallons (, - a - (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 16�D gallons Comments: j� �) Z << [� V EHD Inspector: Reviewed Date: Entered Date: o`Z (b By Initial: By Initial: 1 EHD 28-01 01/16/08