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_ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENI 600 East Main Street,Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:"(209)468-3433 Web:w.ww-Sjgov.org/ehd- ABOVEGROUND PETROLEUM.STORA-GE'PROGRAM SURVEY FORM Facility Name: L I 1 ` D Page of 7. o ZDa/e: Ciy Facility Address: A N rUI Pj TJ U ' ProgramE meat: /� x FA#: =- P b a 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 e. h �ank(2820) ElContainers (2821) :`#of Containers: TA#; i. (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: d gallons install Date: (per tank or cumulative for containers by product type) c ❑ Tank (2820) ❑ Containers (2821) #of Container's: TA#: (>250 gallons) (>55 gallons and 450 gallons) 2 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: 1 (>250 gallons) 05 gallons and 450 gallons) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ElTank (2820) El Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) 4 - Product Type: - Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAM (>250 gallons) (>55 gallons and X250 gallons) 3 5 Product Type: } Total Capacity: gallons ' 1 (per tank or cumulative for con i ers by product.type) Install Dater t z, Total Capacity this Page: ;. gallons Total Capacity for Site: gallons Comments: An EHD Inspector: Reviewed Date: Entered Date: " By Initial: VVJ lay Initial EHD 28-01 01/16/08