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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN" 000 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 Nape: Svc_ A// Page__j_of \ Facility Address: City: Inspec on Datf 17/ k/ Ak V I G FA#: PR#: Program Element: Tank/Container Information _ Complete for all sites with cumulative aboveground storage of petroleum z 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#: ��/!7a (>250 gallons) (>55 gallons and<250 gallons) T 1 Product Type: �1z Total Capacity: /0 0 O gallons (per tank or cumulative for containers by product type) Install Date: ftr Tank(2820) ❑ Containers (2821) #of Containers/. — TA#: a 51 7oZ I I (>250 gallons) (>55 gallons and X250 gallons) 2 Product Type: �Af Total Capacity: 5,0 gallons / (per tank or cumulative for containers by product type) Install ate: 94 k (2820) ❑ Containers (2821) #gf Containers: TA#: 12677 LI (>250 gallons) (>55 gallons and<250 gallons) // Ire _ �� 3 /Product Type: l _ Total Capacity: .�o o D gallons r!i G�rz (per tank or cumulative for containers by product type) Install Date: /i o!3/ T/�iQ� ❑ Tank(2820) ❑ Containers (28 ) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 ga ns) 4 Product Type: Total Capacity: llons (per tank or cumulative for containers by produ type) Install Date: ❑ Tank(2820) ❑ Contai rs (2821) #of Containers: TA#: (>250 gallons) (>55 gallons d<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for contain by product type) Install Date: Total Capacity this Page: b gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: q.-A,04 By Initial: FJ EHD 28-01 01/16/08