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S SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMET`/, 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 Na 7-41;c/z, 1"EA5M1P ce 1,1P Page of Facility Address: City: Inspectionte: �+ U W//�Sf/� G"T ) Tj� O V FA#: PR#: t Program e fil- 6 0 - 2 � Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. D ank(2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) /�f/,-! n �� 19, / 1 Product Type: (. Total Capacity: foS Gam_gallons Install Date: (per tack or cumulative r containers byproduct type) ❑ Tank (2820) RIContainers (2821) #of Contain s: TA#: (>250 gallons) (>55 gallons and<250 gallons) \ / 2 Product Type: Total Capacity: _gallons Install Date: (per tank or cumulative for containers by product type) , El Tank (2820) Ly'Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<50 gallons) 7 3 r Product Type: t'h d/-171�� ![/ Total Capacity: 1-5gallons Install Date: (per tank or cumulative for containers by product type) PTank(2820) ET Containers(2821) #of Containers: TA#: (>250 gallons) , .(>55 gallons and<50 gallons) 4 Product Type: �,�QfL -41Total Capacity: � �2—d gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 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: 7- A / z� L l 3-,zv vv/Lf&- EHD Inspector: Reviewed Date: Entered Date: By Ionia[: \KAx- By Initial: EHD 28-01 01/16/08