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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME'l 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:/ ?/ ! y L- lT / IN /�%S c �/1/�/� %Q�/ Page of Facility Address:� Cit R k Inspect1pn D�lte:,` FA #: 9/5~ PR #: �Z6 Program Elem t: Z$3T 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#: T,gDF� 1�51� 3 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: S o 0 o 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: / d 6 O gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: /i'i_!�q Total Capacity: 3 O 9 (i gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (282 1) #of Containers: TA#: V" & (P 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: ! 0'V � Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) 0 Tank (2820) Containers (282 1) #of Containers: 3 TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: B/ L Total Capacity: / gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: l rJ- gallons Comments: EHD Inspector: Reviewed Date: By Initial: jv,� -� fl� Entered Date: By Initial: J„ EHD 28-01 01/16/08