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SAN JOAQUIN COUNTY \ ALx •ENVIRONMENTAL HEALTH DEPARTN • O_I 600 East Main Street,Stockton,CA 95202- d29 Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.orgJ ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Names, r �� r Page of Facility Address: City: Insp D e: O &f'/ /xl FA#: PR#: Prog`re�m lern t 000 /Z r15 OY Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Com Tete one box for each tank or each cumulative container product type. ❑ Tank(2820) Containers (282 1) #of Containers: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: fy t L O Total Capacity:--�U 61gallonsInstall Date: (per tank or cumulative forcontainersby product type) ❑ Tank(2820) gr6ontainers (2821) #of Containers: TA&--,9n-7tr� (>250 gallons) (>55 gallons and<250 gallons) / 2 Product Type: d/ Total Capacity: for gallons Install Date: (per tank or cumulative for contain by product type) ❑ Tank(2820) Containers (2821) #of Containers: L` TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 _ Product Type: Total Capacity: - `- gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: Y TA#I:.-k)Aj=//v7 4 (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: t-, Total Capacity: 'Za gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: Y TA#; 4,4y[-Lr LP"67 -- (>250 gallons) (>55 gallons and<250 gallons) 5 -Product Type: L Total Capacity:"-2" 1 ons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: .`. gallons Total Capacity for Site: �- 'd gallons Comments: �.. �. �', i 1� EHD Inspector: /fJ _ Reviewed Date: Entered Entered Date: By Initial WN) " 1-�'A By Initial: g v EHD 28-01 01/16/08