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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT *"a&()East Main Street,Stockton,CA 95202-302'r Telephone.(209)468-3420 Far:(209)468-3433 Web.www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 117 7 ' wR 11-2e!122i2 Page o Facility Address: City: Insp o Date: s c 14 ARTiff- W y zy/6P FA#: PR#: Program Element: C0 1 S/-7 -f Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2,1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product ❑ Tank(2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) -- ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TAM (>250 gallons) (>55 gallons and Q50 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Mall Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 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 Q50 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: " - NO L z fVv -'e2 AT T!Jl f O�J/Lr S pwN Olxv I ur AcTit1r EHD Inspector: Reviewed Date: Entered Date: L 9y Initial: vo (P -1+01 By Initial: ERD 28-01 01/16/08