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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEI 600 East Main Street, Stockton,CA 95202-30a9 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: D1 le L Y 0 � /V Page `lam of Facility Address: City: Inspection Date: FA#: PR#: Program Element: Q92- 22 I Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Com Tete one box for each tank or each cumulative container product type. U Tank (2820) Containers (2821) #of Containers: TA#: � Pa (>250 gallons) (>55 gallons and<250 gallons) IProduct Type: -A Fa.,�� Total Capacity: '2-5 gallons (per tank or cumulative for containers by product type) Install Date: a (2820) containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 14It/G Total Capacity: /Z d gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ['Containers (282 1) #of Containers: 3 TA#: 2 3 (>250 gallons) (>55 gallons and<250 gallons) O 3 � Product Type: r/2q!✓S Total Capacity: /0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) EAI!ontainers (2821) #of Containers: TA#: &9 c� (>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) 0 Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: //0 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: a gallons Total Capacity for Site: gallons Comments: �r EHD Inspector: Reviewed Date: U Entered Date: By Initial: V By Initial: EHD 28-01 01/16/08