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SANJOAQUINCOUNTY LENVIRONMENTALHEALTH DEPARTMENT*,,e ' Imo, 600 East Main Street,Stockton,CA 95202-3029 �/{/t(P�Y,/J/ Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: // C) �o17I GV)FI� 2v Page Of Facility Address: City: Inspec' n te: 2, o D • C-n C- 6 fc4es LArvv - 6 FA#: PR#: Program Element: 00 Baa - Z 8 o 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 ❑ Tank(2820) Containers(2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) I Product Type: Total Capacity: Z SD 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) � Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: _ ❑ Tank(2820) ❑ Containers(2821) #of Containers: TAM (>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 (282 1) #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: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or ctmulative for containers by product type) Install Date: _ Total Capacity this Page: Z J-6 gallons Total Capacity for Site: Z gallons Comments: EHD Inspector Reviewed 1 Date: Entered Date: By Initial: 1. .al �,q,�{j By Initial: Q EHD2"I WWW III"' t, 01116/08