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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM 600 East Main Street, Stockton, CA 95202-su29 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r- Q�t� " N3r L)/.f7 �0 P A %�a Page 2- of Facility Address: City: Inspectionate: FA #: q ll PR #: /f Program lement: 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: . TAM (>250 gallons) (>55 gallons and <250 gallons) 1 Total Capacity: Z13-0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) VIContainers (2821) #of Containers: TA#: A,? % (>250 gallons) (>55 gallons and <250 gallons) 2 -?1W Product Type: Total Capacity: :i� V 0- gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) P Containers (282 1) #of Containers: TAM D511� .5 3 (>250 gallons) (>55 gallons and <250allons) ( � . Product Type: Capacity: Total Ca p y: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 Product Type: Total Capacity: �-(� gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) L7 Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) 11 3 Product Type: aim Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons Fotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: By Initial: Entered Date: By Initial: `� l W EHD 28-01 01/16/08