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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT,,� 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax.(209)468-3433 Weh:www,sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: S -j-C eve`./ C, ttla"eles /b,T/[-1 r-y- C19 1%op 0 Page of Facility Add s: City: ij► Inspectioe:)�� SY G Rei alZ� sT � 0 /ylA iiv _ � e nt• A PR#_ Program El 0� qo � �9 D Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >1320 galions in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. PTank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) 1 Product Type: Total Capacity: 3 S0 _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) 2 Product Type: r 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 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons install Bate: (per tank or cumulative for containers by product tvpe) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: �� gallons i Total Capacity for Site: -3J gallons Conunents: 3 EHD Inspector: ,q Reviewed Date: Entered Date: L By Initial: ti Ik 0 By Initial: I O EHD 28-01 01/16/08