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• SAN JOAQUIN COUNTY ` \./ENVIRONMENTAL HEALTH DEPARTMEN7*%d 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: of G (log t(G l voRKS vT/G� ry- J'R/� Ca�'n/jR Page of Facility Address: City: inspection3 -1� O 0 C diS tv % G' l ZD)fjt: FA#: - PA#: Program e) 63 1 R - 'T 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 co e. Tank (2820) ❑ Containers (2821) #of Co ers: TO: (>250 gallons) (>55 gallons and<250 gallons) 1 duct Type: Total Capacity: —�gallons Mall Date: (per tank or cumulative for coraffiers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: 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) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<50 gallons) 3 Product Type: Total Capacity: gallons Date: (per tank or cumulative for containers by product type) Install ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 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<250 gallons) S Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Mall Date: Total Capacity this Page: S gallons Total Capacity for Site: gallons Comments: Af p P EHD Inspector. Reviewed Date Entered Datc. By Initial: ta.10-di By Initial: EHD 2"1 ✓ 01/16/08