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SAN JOAQUIN COUNTY ? �. •� ENVIRONMENTAL HEALTH DEPARTMENT 640 East Main Street,Stockton,CA 95202-34 Telephone:(209)458-3420 Fax.(209)468-3433.Web:'Www.sjgoV.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of a City: InspectionPate:a ,r Facility Address: f /3 p z�9�- G✓ � � -[,I/� . 11 A�r LLA , �I !! FA#: -PR#: Program�gra 06 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320'gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container Rroduct type. ❑ Tank(2820) Em(:ontainers (2821) #of Containers: _Z .TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: = � - Total Capacity: gallons- Install Date: (per tank or cumulative far containers y product type) ❑ Tank(2820) 0 Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) 2 Product.Type:. Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) a ❑ Tank (2820) 0 Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) 3 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) 4 Product Type. Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) { ❑ Tank (2820) ❑ Containers (282 jr) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: . Total Capacity: gallons (per tank or.cumulative for containers by product type) Install Date: Total Capacity this Page: S gallons Total Capacity for Site: ,j S gallons Comments: 13 Zo. 9 l EHD Inspector: 4 Reviewed , '�`` Date: '� Entered Date: 4� 13y Initial: W'v /,.1'} 8y Initial: M EHD2MI 01/16/08