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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN X600 East Main Street,Stockton,CA 95202-30)V- Telephone:(209)468-3420 Far.(209)468-3433 Web.www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Na e: Page�_of -p l L v c ��, �FSR� TR A G/o R- CO Facility Address: ^� City. E/� tnspecti�Da f Z / 9figA107 FA#: PR#: Program Gv Oen�f✓ Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. CoEMIate one box for each tank or each cumulative container product type. ❑ Tank(2820) VrEontainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) �' 1 Product Type: _�� Total Capacity: SS gallons Install Date: (per tank or cumulative for containers by product type) L�1'ank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: /UI 072MI /9// Total Capacity: -/ -Z-0 gallons Install Date: (per tank or cumulative for containers by product type) (-ank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: f -L02 gallons Install Date: (per tank or cumulative forco�ont//ainers by product type) _ ❑ Tank(2820) EWC"ontainers (2821) #of Containers:, / TA#: (>250 gallons) gallons and<250 gallons) 4 Product Type: z�oc4p/Zi Or �✓ Total Capacity: "S:,!r gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) Containers (2821) #of Containers: 41- TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: Zza gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page. f'7 O gallons Total Capacity for Site: 5 2,9 gallons Commen EHD Inspector: Reviewed I Date. .I Entered Dalejj r By Initial: ..1 �.(a.�p By Initial: (p EHD 28-01 01/16/08