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d SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT D 600 East Main Street, Stockton, CA 95202-30L Z Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: � �, (-0Page of Facility Address: city, X� 0 �1 InsAh pe io Date: l 6 0 FA #: �c�o 3 PR #: Z Z Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >:1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (282 1) #of Containers: I--, TA#: ,9 5/�j J� % 1 (>250 gallons) (>55 gallons and <250 gallons) 3 6O Product Type: p) � Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) Containers (2821) #of Containers: G TA#: Vt— 2{/ (>250 gallons) (>55 gallons and <250 gallons) Product Type: (3/ C- . Total Capacity: /o D O gallons (perk or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: 5 d gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TAM /LPVC�D 4 (>250 gallons) (>55 gallons and <250 gallons) Total Capacity: 296 Product Type: —',� r�,/j.S�`/✓ gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: ? ZIPgallons Total Capacity for Site: 2,724 gallons Comments: EHD Inspector: Reviewed By Initial: Date:Entered 6-t4-ati I /n Date: By Initial: �Y (/ !� EHD 28-01 01/16/08