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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN- o00 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 Na e: p Svc- /5/('/ Page of \ Facility Address: City: Inspec on Datf: D/ k/ Z �0 z 9 10-3 FA#: PR#: Program Element: t L3 ) 1 05--*�'a zg '�� 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 (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) T 1 Product Type: f.��f �� Total Capacity: /0 0 O gallons (per tank or cumulative for containers by product type) Install Date: Q'Tank(2820) ❑ Containers (2821) #of Containers: TA#: d 5172. (>250 gallons) (>55 gallons and<250 gallons) � 2 Product Type: Total Capacity: 5,00 gallons (per tank or cumulative for containers by product type) Install Date: L'Tank (2820) ❑ Containers (2821) #of Containers: TA#: '� (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: f _ Total Capacity: J6 o D gallons Install Date: / 013/ (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 (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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: o b gallons Total Capacity for Site: (1 400 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: VNOq, ,p`�j By Initial: 0 EHD 28-01 01/16/08