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e SAN JOAQUIN COUNTY �" v, SNV[RONMENTAL HEALTH DEPARTMENT - t # 600 East Main Street,Stockton,CA 95202-302 Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: t—/ 7"y_ 0� GOA/ - ,groex .4.41.0AOCR49ra Page—Lof Facility Address: City: Inspection ate• i N STo o�,TvW S7' - o SZ FA#: -PR#: Program lement: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Cam let one box for each tank or each cumulative container product type. ❑ Tank(2820) - ontaincrs (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) Product Type: a ryfz / �r Total Capacity: Ir gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ED-1 ontainers (2821) #of Containers_: TA#: y (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: S. gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) LAS Containers (2821) #of Containers: TA#: r` {>250 gallons} (>55 gallons and 450 gallons) - 3 Product Type: � �0��d Total Capacity: . _,gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) U21/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 450 gallons) 5 Product Type: --•-- Total Capacity: t�P gallons (per tank or cumulative for containers by product type) Install Date' Total Capacity this' ` gallons Total Capacity for Site: `Z Z gallons Comments: EHD Inspector: Reviewed Date: Entered Date: `By Initial: f 'a'ip- By Initial: r EHD 28-01 01/16/08