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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMD 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: Page of Facility Address:'City: ST Inspe on ate, Cr-iJTf �� 5 3o a� FA #: dao9�� PR #: 5-z-37 S6 3 Pro ra E menta ) 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#:§U`��y!'o2 (>250 gallons) (>55 gallons and <250 gallons) 1 Product Type: Z2, P,� Total Capacity: 1 D O d gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 2 Product Type: Z'E"' s tS' Total Capacity: p 4" gallons 1/0 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 3 Product Type: Total Capacity: 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) 4 Product Type: Total Capacity: 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: Zd p gallons Fotal Capacity for Site: 2— D Ov gallons Comments: 23 -20 /,�z EHD Inspector: C ReviewedI By Initial: Date: � 5.3"• D� Entered Date: By Initial: D EHD 28-01 01/16/08