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SAN JOAQUIN COUNTY :NVIRONMENTAL HEALTH DEPARTMENT b00 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 61-f s% e) 0 % 4'A/ Page of Facility Address: City: IVITI CA Inspection D te:A i o FA #: PR #: ©— g — Program Element: z 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#: &6j -1'`j D (>250 gallons) (>55 gallons and <250 gallons) 1Product Total Capacity: SO O gallons Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: ✓ Sy gallons (per tank or cumulative for containers by product type) Install Date: "nk (2820) ❑ Containers (2821) #of Containers: TQC#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: .So D gallons Install Date: (per tank or cumulative for containers by product type) Eiiank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 Product Type: �,.�A Total Capacity: S_�0_161 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: �ij 0 gallons Fotal Capacity for Site: S gallons Comment EHD Inspector: — \ Reviewed Date: By Initial:V\' tu,�,4l: Entered Date: By Initia P 7 EHD 28-01 01/16/08