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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEOW 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: P e f �/ pt g Facility Address)�3 Cit Inspecti Date: l y v /`� /� ✓ D LAW FA#: •• ft t PR#: ' Program lemeat: 6.5a `L%Vj 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#: ahs 75- (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: v;;_0 —" 0 2 O � L' Total Capacity: SD 0 gallons Install Date: (per tank or cumulative for containers by product type) L4"fank (2820) ❑ Containers (2821) #of Containers: TA#: 4:571!74-71P (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: ,L��YD/LAG/r✓ o/ l/ Total Capacity: s e"gallons stall 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: &A/1/ PJ�- Total Capacity: f3" gallons Install Date: (per tank or cumulative for containers by product type) El Tank (2820) L7Containers (2821) #of Containers: TA#: 79 (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: 11V gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) []'Containers (2821) #of Containers: TA#: q 79 5 (>250 gallons) (>55 gallons and<250 gallons) Product Type: /11 r/r—� Total Capacity: 1 5� gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Pa e2- gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: �V EHD 28-01 01/16/08