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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME] 600 East Main Street, Stockton,CA 95202-30zy Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: -D�rO �✓ S 7`4 1/ C-7/0/k/ Page�_of Facility Address: City: Inspec6,ti n Dat i1 FA#: PR#: Program EI ent: 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: - TA41. (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: IV Total Capacity: /Q Op(y gallons Install Date: (per tank or cumulative for containers by product type) E] Tank (2820) ❑ Containers (2821) #of Containers: /TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: C3/ Total Capacity: S'-S-6 gallons (per tank or cumulative for containers by product type) Install Date: 17�ank (2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 - Product Type: O� Total Capacity: .�-J U gallons (per tank or cumulative for containers by product type) Install Date: C1.:T-Ank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) / 4 Product Type: Total Capacity: 1`-I gallons (per tank or cumulative for containers by product type) Install Date: /ank(2820) ❑ Containers (2821) #of Containers: TA#: (9 ! (Q g D (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: 0/ �/ Total Capacity: P 5 O gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: 1Z EHD 28-01 01/16/08