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SAN JOAQUIN COUNTY �:'ENVIRONMENTAL HEALTH DEPARTMEN' 00 East Main Street,Stockton,CA 95202-302 v Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 6 f� fifl, - 9 Page of Facility A dress: City: Inspectlo Da e: W S T Q 6�7 FA#: 2, PR#: Program Elem t: /o � Drag 8 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ;2:1320 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) 1 Product Type: Total Capacity: 0 O gallons (per tank or cumulative for containers by product type) Install Date: 1 ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and 450 gallons) { 2 Product Type: Total Capacity: gallons . (per tank or cumulative for containers by product type) Install Date: } ❑ Tank(2820) ❑ Containers (2821) #of Containers: .TA#: I (>250 gallons) (>55 gallons and 450 gallons) 3 Product-Type: Total Capacity: gallons ' I - (per tank or cumulative for containers by product type) Install Date: ❑ Tank 2820 ❑ Containers 2821 t Tank(2820 ( ) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) .4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers(2821) #of Containers: TAM ( 250 gallons) (>55 gallons and<250 gallons) Product Type: . Total Capacity: gallons (per tank or cumulative for containers by product type) Instal l Date: Total Capacity this Page: gallons Total Capacity for Site: " Q gallons -Comments: EHD Inspector: ReviewedDate: Entered Date: 't By Initial: (,� p) Q By Initial: i EHD 28-01 01/16/08