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SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT 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 Facilit � Page of Facility Address: Z. City: �3�dAnwAY AV6 s�-k Inspect' n Date: oy �� 2- FA #: PR #: Program m t• VC-) Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum > 1320 gallons in tanks and containers over 55 g4orts. Complete one box for each tank or each cumulative container ttct yti�pe. �- I Tank (2820) ElContainers (2821) #of Coa hers: TA#: 1oduct (>250 gallons) (>55 gallons and <250 gallons) Type: �� Total Capacity: ! O Oa O Install Date: �"l '>/� (per tank or cum t+ or containers by product type) J Tank (2820) ElContainers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 s �- Product Type: zo, 411 D --� Total Capacity: /U gallons (per tank or cum or containers by product type) Install Date: LWTank (2820) ❑ Containers (2821) #of Containers: TA#: �`�(� It I 3 (>250 gallons) (>55 gallons and <250 gallons) ('5Cq Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and <250 gallons) 4 - Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: 1 S S �i 37 n 3 AJAM C 4 EHD Inspector: Reviewed Date: / By Initial: � S� 1'l �� i Entered Date: By Initial: EHD 28-01 01/16/08 /2. hog 2)