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` SAN JOAQUIN COUNTY (' ,-NVIRONMENTAL HEALTH DEPARTMENT '1600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web.-www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: D -r , Page of �� Facility Address: City: lnspectio D e: s o CA65 n- d � FA#: PR#: Program lenient: Tank/Container Information Complete for all.sites with cumulative aboveground storage of petroleum L>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 Product Type: " Total Capacity: E0 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 X250 gallons) 3 Product Type: Total Capacity: gallons ` (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers byproduct type) ❑ Tank (2820) ' ❑ Containers (2821), ##of Containers: TAM (>250 gallons) (>55,gallons and X250 gallons), 5 Product Type: Total Capacity: gallonsI (per tank or cumulative for containers by product type) Iri5ta11 Date: Total Capacity this Page: S-'(J gallons Total Capacity for Site: 4'S—A-3 gallons F Comments: Y' EHD Inspector: Reviewed Date: Entered Date: " By Initial: __3 a_� 0� By,. t7 �j EHD 2"1 01/16/08 ii