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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME'i 600 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: tV T -- �, T kQ �r Page of Facility Address: ^ D-0 �• �T City: C % p Inspectionat C 61 FA #: � � � PR #: `/ � n Program le ent: 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#: B6 -1&10,e 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: %�� Total Capacity: % o 6 O gallons Install Date: tank or cumulative for containers by product type) GY(per Tank (2820) ❑ Containers (2821) #of Containers: TA#: / (>250 gallons) (>55 gallons and <250 gallons) -�qi�- 2 Product Type: Total Capacity: /cod gallons (per tank or cumulative for containers by product type) Install Date: L,d `1 ank (2820) ❑ Containers (2821) #of Containers: TAM —I le (!,9 ,5/ 3 (>250 gallons) (>55 gallons and <250 gallons) / Product Type: (�/� Total Capacity: 5 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) 4 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) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: Z rj o a gallons FTotal Capacity for Site: '2, -T-19 6) gallons Comments: Z 3� 2- (!'l O, EHD Inspector: �. Reviewed at : By Initial: Entered By Initial: Date: L, EHD 28-01 01/16/08