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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:,r /II %� (� L �� r / '� /— Page 21 ofy Facility Address: City: Inspection•v tae: fz 0 FA #: PR #: Prog a leme : Tank/Container Information Complete for all sites with cumul 've aboveground storage of petroleum >_ 1320 gallons in tanks and containers over 55 gallons. C0�16ete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers: TA#:) 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: Z 6 �-r gallons (per tank or cumulative for containers by product type) Install Date: U?" T ank (2820) ❑ Containers (2821) #of Containers: TA#: z9L!5 / 1P (>250 gallons) (>55 gallons and <250 gallons) � •' �S 2 Product Type: p / iC®Q Total Capacity- 0 C _ gallons (per tank or cumulat. _ .. _ .. ....� Uy product type) Install Date: ❑ 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: gallons FTotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: W l� !� EHD 28-01 01/16/08