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SAN JOAQUIN COUNTY . NVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: �:5"jC-6 For') C Page I of a Facility Address City: ., Inspection Date: OjF f Z -q-Ox FA#: PR#: Program Element: � C ` .5(le Z 832- 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#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: �� ' Total Capacity: J gallons (per tank or cumulative for cohtainers by product type) Install Date: ❑ Tank(2820) 0 Containers (282 1) #of Containers: TA#:��q� (>250 gallons) (>55 gall ns and<250 gallons) 2 [ Product Type: �� `�'Q m5 l Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: I TA#: ( )&7?Q 3 (>250 gallons) (>55 gallons and<250 gallons) rl 4�Product Type: M (J'i'b Total Capacity: 1,50 gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) El Containers (2821) #of Containers: TA#: I�� (>250 gallons) (>55 gallons and<250 gallons) ` 4 Product Type: 7� 14"r J'�- riyO `I 4NShm,1,,V Total Capacity: �3U 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: gallons Total Capacity for Site: 2 gallons Comments: EHD Inspec or: Reviewed i, pate: Entered ate: By Initial: V� 3l�O 6 By Initial: L EHD 28-01 01/16/08