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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME . 00 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 Name: _ o Cf1 ) Z E v/ n'J N I �/�NT/� C/ Page _of Facility Address: City: Inspec ion Date: 01005 vA�� G T' liN C- 14 G te!As� b FA#: PR#• Program Element: g� 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. UI'ank(2820) ❑ Containers (2821) #of Containers: _ TA#: (��/�� (� (>250 gallons) (>54�,gallon d<250 gallons) 1 X100 Product Type: , Total Capacity: / G d gallons Install Date: (per tank or cumulative f ontainers by product type) ank(2820) ❑ Containers (2821) #of Containers: TA#: Q,JJpo2� (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: ,S'O 6 gallons (per tank or cumulative for containers by product type) Install Date: X Tank(2820) ❑ Containers (2821) #of Containers: TA#: O k5) q&O g (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: A4q-1Y-d) Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ElContainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: 12-1 gallons IV (per tank or cumulative for containers by product type) Install Date: Tank(2820) El Containers (2821) #of Containers: TA#: LP D 250 gallons) (>55 gallons and<250 gallons) 5 Product Type: ' Total Capacity: OW gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: /Z U O gallons Total Capacity for Site: gallons Comments: o4-rLA L&F Cr - s� l EHD Inspector: Reviewed Date: a Entered Date: C By Initial: wtl ��1'ti' By Initial d EHD 28-01 01/16/08