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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton, CA 95202-30/-, Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: " / 7i O N / zile -TS Page of Facility Address: City: Inspectio Date, frcC-0A-jP 37' 6 4,2 Al ?� /F FA #: PR #: Program Ele ent: r-7:2 3 9 j fZj 7 2 6' 2 l Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ;2t 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 Total Capacity: 1.5-016 Product Type: /Ai� 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) 2 Product Type: Total Capacity: 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) 3 Product Type: Total Capacity: 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) ❑ Containers (2821) #of Containers: TA#: (>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: 1 gallons Total Capacity for Site: ✓C9 0 gallons Comments: CA05'Sf,T STS M4�r� EHD Inspector: Reviewed Date: Entered Date: r By Initial: S -� 0 p� VAI By Initial: EHD 28-01 01/16/08