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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT o00 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Weh: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: % T Page of % Facility Address: City: GV o ,/T S �Ur Ins pec 'on ate• 6%310 � FA #: nD�PR �`z`S� #: Program Element: zg3/ 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. EP'Tank (2820) ❑ Containers (2821) �[ #of Containers: TA#• lie (>250 gallons) (>55 gallons and <250 gallons) 1 Product Type: Total Capacity: 3 d 0 '6 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: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>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 (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: 30 4D gallons Total Capacity for Site: O m d gallons Comments: L Vl-e -r EHD Inspector: n ` Reviewed By Initial: Date: (J �. �. 6� Entered DatazffL By Initial: %%%) EHD 28-01 01/16/08