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SAN JOAQUIN COUNTY , ENVIRONMENTAL HEALTH DEPARTMEN-k 600 East Main Street, Stockton,CA 95202-3027' Telephone:(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 7 X UC/ AA1� T,O��. �`� ��n��G` d3�2�S �. { /i S- Page of�_ Facility Address: City: tnspcctio Dat . /� 4666D SVA176S 4 � �Lj d G a 2 p FA#: fPR#: Program'Element: 40 Tank/Container Information, Complete for all sites with cumulative aboveground storage of petroleum z'1320 gallons in tanks and containers over 55 gallons. Complete one box for each'tank or each cumulative container product type. Er'Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 0150 gallons) 1 'Product Type: 1.'A S'Trr 0-C Total Capacity: 3 D gallons T (per tank or cumulative for containers by product type) Install Date' 0�iank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) .(>55 gallons and 450 gallons) 2 ,l .Product Type: / 0 7 eln__ D Total Capacity: 3 o D gallons- (per allons-(per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers:, TAM (>250 gallons) (>55 gallons and 450 gallons) q- 3 Product Type: ..^/�D Total Capacity: 3069;illons (per tank or cumulative for containers by product type) Install Date: 0 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 by 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 cumulative for,containers by product type) Install Date: Total Capacity this Page: _ gallons Total Capacity for Site: P0 gallons EHD Inspector: Reviewed Date: Entered Date: % �'� By Initial: U,�,�$ By Initial: `B 7 .) EHD 28-01` ' y 01/16/08