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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ` 00 East Main Street, Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Na e: _ j lJ 1g � � P N S D T Page_L_of _ Facility Address: City: Inspection Date- 3 ) R Pz4 FA#: PR#: Program Element: 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: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: ;-ti d 7-'q i2 Total Capacity: 'b D gallons (per tank or cumulative for containers by product type) Install Date: U;KTank (2820) ❑ Containers (2821) #of Containers: TA#: _ (>250 gallons) (>55 gallons and<250 gallons) /�✓� 2 Product Type: 4I/�,�f� �f 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) 3 Product Type: Total Capacity: 6�z> gallons Install Date: ' (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: _ TAM 1-7 14 �� (>250 gallons) (>55 gallons and<250 gallons) I 4 Product Type: Total Capacity: �j jj D� gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: / 2, 9 d a gallons Total Capacity for Site: /Z 9d 6 gallons Comments: T v o2 EHD Inspector: Reviewed Date: / Entered Dater C By Initial: VA 1 By Initial: `7 EHD 28-01 / 01/16/08