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SAN JOAQUIN COUNTY sNVIRONMENTAL HEALTH DEPARTMEN 000 East Main Street,Stockton,CA 95202-3029 r Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: L )' � u � /---- V 1 Pag of Facility Address: City Inspect' n/D te: U s Ls6 ry � S�/�— 6 FA#: PR#: Program Element: 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. ank (2820) ❑ Containers (2821) #of Containers: TA#: n (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: I-4//T Total Capacity: 50 a 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) 2 Product Type: Total Capacity: / 0 d 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) 3 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) 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) 5 Product Type: Total Capacity: 9 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ons Total Capacity for Site: Z 0© gallons Comments: EHD Ins tor: Reviewed Date: Entered Date: By Initial: By Initial: /�( EHD 28-01 01/16/08